Need health and medical help with a Neurology Case Study

Please read the below scenairo and answer the questions following it.  Thank you!

CC:  AK is a male, age 42, who presents to your clinic complaining of headache pain, with nausea and vomiting.  AK has 2 to 3 headaches per month.  This particular headache began two days ago.  It is best described as bilateral, dull, throbbing pain.  The pain has been so severe that he is not able to work.  He has been taking Aleve 200mg every 8 hours without relief.

PMH:  GERD x 5 years
Chronic migraine H/As

Medications:
Aleve 200mg Q8 hours prn H/A

Allergies:  penicillin (rash)

SH:  6 cups of coffee per day and about 4 cans of Pepsi; no acohol or tobacco

Physical Examination:
GEN:  obese male in moderate distress
VS:  BP 128/80, HR 70, RR 14, T 98, Wt 100kg, Ht 6’0”
HEENT:  PERRLA, photophobia, normocephalic, atraumatic
COR:  normal
CHEST: normal
ABD:  normal
RECT:  guaic-negative
EXT:  normal
NEURO:  oriented to time, place and person; normal deep tendon reflexes

Laboratory:  WNL

  1. What major problems can you identify with this patient?
  2. What is your assessment and plan for each problem? 
    1. Provide pharmacological and nonphamacological care (don’t forget to be specific with medicatins and dosing).  Will you discontinue any medication that the patient is currently taking and/or add any new medications?
    2. How will you monitor each problem and each medication included in your plan?
    3. When will you suggest following up with the patient?
    4. Is there any laboratory monitoring that will need to be conducted to assure the safety of the patient?

Expert Solution Preview

Introduction:

This patient presents with symptoms of a headache with associated nausea and vomiting. The patient has a history of chronic migraines, GERD, and is currently taking Aleve for headache relief. In this scenario, the medical professor must evaluate the patient’s overall health status and come up with an appropriate plan of care that addresses the patient’s concerns.

1. What major problems can you identify with this patient?

The major problems identified in this patient include the presence of a severe headache with associated nausea and vomiting, chronic migraines, and GERD. The patient’s obesity may also be a contributing factor to their headaches.

2. What is your assessment and plan for each problem?

a. Headache: The patient’s headache requires immediate attention. Non-pharmacological treatments such as rest and hydration may be beneficial. However, pharmacological treatment may be required to alleviate the headache. Triptans, ergotamines, and NSAIDs are commonly used to treat migraines. In this case, the patient is already using Aleve, and an increase in dosage may be considered. Alternatively, a combination of acetaminophen, aspirin, and caffeine may be considered. The dosage of each medication should be prescribed based on the patient’s weight and current conditions.

b. Chronic migraines: The patient’s chronic migraines require prophylactic treatment to prevent the onset or reduce the frequency of headaches. Beta-blockers, calcium channel blockers, anticonvulsants, and antidepressants are commonly used in prophylaxis. Topiramate, valproic acid, and amitriptyline may be considered in this case. The dosage of the medication should be prescribed according to the patient’s current conditions and contraindications.

c. GERD: The patient’s GERD is a chronic condition that requires long-term management. Lifestyle changes such as weight loss, dietary modifications, and smoking cessation may improve the condition. Proton pump inhibitors (PPIs) and H2 receptor antagonists are commonly used in GERD. PPIs are more effective than H2 receptor antagonists and may be preferable in this case. Omeprazole, pantoprazole, and lansoprazole are commonly used PPIs. The dosage of the medication should be prescribed according to the patient’s weight and current conditions.

3. How will you monitor each problem and each medication included in your plan?

Each problem and medication should be monitored according to the patient’s response and the expected outcomes. The patient should be asked to keep a record of the frequency and severity of headaches, any relief after taking medications, and any other symptoms associated with GERD. The medication should be monitored for side effects, interactions with other drugs, and adherence to the prescribed therapy.

4. When will you suggest following up with the patient?

The patient should be followed up within a week after the initial visit to assess the response to the prescribed therapy. Further follow-up visits should be conducted regularly to monitor the patient’s response and adjust the therapy accordingly.

5. Is there any laboratory monitoring that will need to be conducted to assure the safety of the patient?

Laboratory monitoring may be required for patients receiving certain medications such as valproic acid, which may reduce platelet counts. However, in this scenario, no laboratory monitoring is required as the patient is taking medications that do not require regular laboratory monitoring.

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