- 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 â€“ 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 â€˜Pâ€™ in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the â€˜headingâ€™ and after the â€˜:â€™ input N/A]
Therapeutics:pharmacologic interventions, if any â€“ 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 â€˜therapeuticsâ€™ 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 â€˜Advanced Care Planningâ€™ with the patient/patientâ€™s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate â€“ 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 â€˜Pâ€™ with scholarly resources.