: Headache Case Study: Rob is a 44-year-old carpenter who comes to the emergency department complaining of a severe headache. The nurse has began gathering
: Headache Case Study: Rob is a 44-year-old carpenter who comes to the emergency department complaining of a severe headache. The nurse has began gathering data: Interview Data: When the nurse begins to ask Rob about his headache, he immediately cries out, “I can’t take this anymore! It hurts too much!” His wife says that Rob has been getting these headaches a couple of times a day for the past week now-sometimes at night-so he is not sleeping well. She also explains that he had headaches like these about a year ago and they lasted about a month. The nurse asks Rob if he experiences any nausea or sensitivity to light, he replies “No, I just get a stuffy nose.” His wife says that they are worried because we don’t know what’s causing them, and nothing seems to them go away.” Physical Examination Data: General Survey: Alert, well-nourished man of average weight, in moderate distress. He is unable to sit still and paces the floor in the examination room, holding the left side of his head (over his eye and forehead). Head & neck: Skull is intact, with no lumps, depressions, or tenderness. No abnormalities are found with facial structures. The head is centered on the neck; the trachea is midline. Thyroid is in midline position and of normal size. 1. What data deviate from the normal findings that suggest a need for further investigation? 1
2. What additional questions should the nurse ask to clarify the patient’s symptoms? Use the OLDCART mnemonic. 3. What additional examination data should be obtained?
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