- 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
Utilize the information provided in the scenario to create your discussion post.
Construct your response as an abbreviated SOAP note (SubjectiveObjectiveAssessmentPlan).