Assess the location (parietal, occipital, lateral etc. ), severity and characteristic (radiating, sharp, isolated, dull etc. ) of the headache. Assess visual acuity and function using a pen light. Use a tuning fork to assess any hearing or vestibular problems (observe for lateralization of sound). Use the reflex hammer to assess the presence of abnormal reflexes such as Babinski’s, Hoffman’s or Chyaddock’s reflex.
Have the patient characterize the funny sensation (pins and needles, numbness etc. ). Have the patient perform some tests for balance to assess coordination. Musculoskeletal System: Assess for weakness and /or loss of function. Have the person perform stationary muscle exercises and some basic range of motion exercises. Physical Assessment Tools Pen light, tuning fork, reflex hammer, pain charts. Clinical Inferences
Given the family history and the presenting symptoms it must be taken into account that the client may be suffering from an inherited autoimmune disease such as Multiple Sclerosis or even the presence of a brain tumor. According to various literature, the common presenting symptoms of Multiple sclerosis [MS] includes loss of balance, weakness in some or all limbs and tingling and numbness in the peripheral regions (Smeltzer & Bare, 2004; Wilkins et al, 2008; Williams & Suddarth, 1991). Occasionally, the patient may also present with headaches.
Furthermore, given the history, the client and the grandfather fit the at risk population of males above 60 and women aged 40 or below. MS is a genetic disease and is thought to be an inherited condition. However, the presenting symptoms are also typical of some brain tumor presentation which has headaches listed as a primary symptom. Depending on the area of affectation, symptoms such as peripheral neuropathies and weakness, loss of balance or coordination may be present (Smetlzer & Bare, 2004).
A CT scan and genetic testing may be required to fully diagnose the client. References Smeltzer, S. C. , & Bare, B. G. (2004). Brunner & Suddarth’s textbook of medical-surgical nursing. (10th ed. ) Philadelphia: Lippincott Wilkins. Kozier, B. , etal. (2008). Kozier & Erb’s Fundamentals of Nursing. (10th ed. ). Prentice Hall. Williams & Suddarth, D. S. (1991). The Lippincott manual of nursing practice. (5th ed.). Philadelphia: J. B. Lippincott Company.