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A nurse is caring for a client in the outpatient primary care provider’s office. Nurses’ Notes Two Days Ago: The client presents to the office today reporting irritability and fatigue, and states that light is hurting their eyes. The client states, “Maybe it’s my hormones?” Physical Exam: General: no acute distress, appears agitated Respiratory: breath sounds clear bilaterally Cardiovascular: S1, S2, no murmur Gastrointestinal: soft, non-distended, non-tender, no nausea or vomiting Neurologic: CN II-XII intact HEENT: No ringing in the ears, no other visual disturbances except photophobia Past Medical History: Client reports a similar headache 3 months ago, but it was not this bad. Client reports no previous history of seizures, hypoglycemia, or Bell’s palsy No family history of migraine. Client takes no medications currently. Today, 0800: The client returns to the office and states, “My eyes are still sensitive to light and now I have a terrible headache on the left side of my head. It’s so bad I almost couldn’t get out of bed. When I left the house and the sun was shining, it was the worst pain ever!” Pescador Ruschel
SCIENCE
HEALTH SCIENCE
NURSING

 
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