NU636- unit 7 discussion Migraine

• 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

Construct your response as an abbreviated SOAP note (SubjectiveObjectiveAssessmentPlan).

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/patient’s 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

Support the interventions outlined in your ‘P’ with scholarly resources.

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