18 Nov CC: AK is a 42 year old male who presents to your clinic complaining of headache pain

Case Information:

CC: AK is a 42 year old male who presents to your clinic complaining of headache pain, with

nausea and vomiting. AK has 4-5 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 naproxen (Aleve®) 220mg every 8 hours without

relief.

PMH:

GERD x 5 years

Chronic migraines x 3 years

Medications:

Aleve 220mg every 8 hours as needed for migraine

Allergies: NKA

SH: 6 cups of coffee per day and about 4 cans of Pepsi/day; no alcohol 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: guaiac-negative

EXT: normal

NEURO: oriented to time, place and person; normal deep tendon reflexes

Laboratory: WNL

Previous MRI (1 year ago): no abnormal findings

Important considerations for creating a SOAP note:

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

2. What subjective/objective information in the case supports each of those

problems? Please list only information that pertains to each problem under each

problem.

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

a. Provide pharmacological and non-pharmacological care (don’t forget to be

specific). Will you discontinue any medication that the patient is currently taking

and/or add any new medications?

b. Include your therapeutic goals for each problem (use the subjective and objective

information listed above to help you)

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

d. When will you suggest following up with the patient?. Is there any laboratory monitoring that will need to be conducted to assure the patient safety.

.1. Using the Cockcroft-Gault equation, calculate creatinine clearance for the

following patient: 70 year old female, 5’6” tall, 150 lb, SCr = 1.2 mg/dL.

Round your answer to the nearest 1 mL/min.

2. A 10-year-old female weighing 80 lbs presents with a urinary tract infection

and will be treated with sulfamethoxazole/trimethoprim (Bactrim®). Dosing

for this medication is typically based on the trimethoprim component.

Suspension is available as 200 mg of sulfamethoxazole and 40 mg of

trimethoprim in every 5 mL. Dosing for this indication is trimethoprim 8

mg/kg/day divided every 12 hours. How many milliliters of

sulfamethoxazole would be given with each dose? Round your answer to the nearest 0.5 ml.

nearest 0.5ml