Online Class Activity – Case Study # 1- Headache
Name: Laura Jackson Age: 39
Chief Complaint (CC): Headache
The nurse educator is working in a primary care setting. The next patient is a 39 year-old who is coming in for evaluation of her headaches.
Vital Signs: BP 110/80; Heart Rate 72 bpm; respirations 20 breaths per minute; temperature 98.1Â°F
Answer and support the following questions about the subjective data:
Determine specific questions the nurse educator could ask the patient related to the history of present illness
Discuss the specific past medical history important to know for this patient
Identify specific information that would be helpful in the patient’s family history
Identify specific information that would be needed about the patient’s social history
Explain what systems need to be included in the review of the systems and describe the specific information needed for each of the systems
- How can you describe the headache to me?
- When did the headache begun?
- Are there things that make the headache worse?
- Are there things that relieve the headache?
- Are there any sensory or visual auras?
- How frequent are your headaches?
- Have you had over the counter drugs for the headache?
- Is your headache linked to any changes in vision and feelings of dizziness?
- Is your headache interfering with any normal activities of daily living?
- Do you experience any vomiting or nausea?
- How severe is your headache in scale of 1-10?
Past Medical History
The past medical history of the patient allows the physician to examine and understand which triggers are responsible for the headache. If the patient directly recognizes their headache triggers then it’s possible to avoid them thus treating the headache. Therefore, there are specific past medical history that are vital to known for the patient. These include the changes in the pattern their headaches, the occurrence and history of the headaches, any previous hospitalization, intracranial bleed, surgeries, history of head trauma and any family history of migraines and headaches. The information that would be helpful in the patient’s family history would be a record of the siblings or parents’ problems with headaches or migraines. This is because migraine family history is the most consistent and potent risk factor of headache
Patient’s Social History
Exploring the patient’s social history helps understand the social context and recognize the potential risks factors causing the headaches (Bickley et al., 2020). The patient’s social history needed in the assessment of the headache will include their surrounding and accommodation settings, their current occupation, record of the patient’s smoking history, drug and alcohol drugs, recreational drug use, living situations and activities of daily living.
Review of the Systems
The review of the systems is a list of systems that are acquired from a sequence of questions to identify the symptoms thats the patient may be undergoing (Bickley et al., 2020). Therefore, the review of systems will include the Head, Ears, Eyes, Nose, Throat, Cardiovascular, Respiratory, Skin, Musco-skeletal, and Genito-Urinary.
Head symptoms will include head congestion, headache, recent trauma and dizziness. The ears will be assessed for symptoms like severe pain and ringing ears. The eyes will be assessed for double vision, loss of vision, blurred vision and eye pain. The nose will be assessed for symptoms such as nasal congestion and nose bleeding. The throat will be assessed for symptoms like sore throat, swollen glands and hoarseness.
The cardiovascular will be assessed for palpations, chest pain, peripheral edema, orthopnea and dyspnea. The respiratory will be assessed for cough, chest pain and dyspnea, genito-unitary will be assessed for symptoms such as volume of urine, urgency, frequency and incontinence. The skin will be assed for skin breaks, rashes, lesions and ulcers. The muscu-skeletal will be assessed for joint and bone pain and muscular pain.
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2020). Bates’ pocket guide to physical examination and history taking. Lippincott Williams & Wilkins.