Description
A 46-year-old white male comes in for evaluation of his migraine headache management.
- His medical history is inclusive for hypertension and a myocardial infarction at the age of 39. He was diagnosed with migraine headaches three years ago.
- Current medications include Losartan 50 mg a day, verapamil SR 100 mg at bedtime, Carvedilol 25 mg a day, Lipitor 40 mg a day, Topamax 50mg a day
- He has been admitted to the hospital for migraine management 3 times over the last 6 months. Inpatient admissions have ranged anywhere from 3 to 6 days. Management strategies utilized during the hospitalization include IV corticosteroids, IV Dilaudid and IV magnesium sulfate.
- BP 132/84, P 82, R 15
- Skin: pink, warm, dry
- Neuro: alert and oriented, CNs II XII intact
- Cardio: radial and pedal pulses 2+, heart regular rate and rhythm without murmur or gallop
- Lungs: clear to auscultation
- Abdomen: large, non-distended, active bowel sounds all quadrants, non-tender to palpation
Please develop a discussion that responds to each of the following prompts. Where appropriate your discussion needs to be supported by scholarly resources. Be sure to include in-text citations in the context of the discussion and provide a full reference citation at the end of the discussion.
Initial post
Utilize the information provided in the scenario to create your discussion post.
Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan).
Structure your P in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the heading and after the : input N/A]
Therapeutics: pharmacologic interventions, if any new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional – any other therapies in lieu of pharmacologic intervention]
Educational: health information clients need to address their presenting problem(s); health information in support of any of the therapeutics identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit
Consultation/Collaboration: if appropriate – collaborative Advanced Care Planning with the patient/patients care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making
