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

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?

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