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Patient Case Presentation

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Patient Case Presentation

  1. 1. Dr. Jennifer E. Heasley Mylan School of Pharmacy Duquesne University Ambulatory Care Resident August 25, 2009
  2. 2. Patient Information <ul><li>TK is a 27 year-old African American female </li></ul><ul><li>Generally good health </li></ul><ul><li>No known drug allergies </li></ul>
  3. 3. Chief Complaint <ul><li>Seen at Catholic Charities on 7/29/09 complaining of migraines </li></ul><ul><li>Also currently complains of: </li></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>Dysmennorhea </li></ul></ul>
  4. 4. History of Present Illness <ul><li>Diagnosed with migraine headaches when she was a teenager </li></ul><ul><ul><li>Tried Advil 200mg and Tylenol 325 mg in the past with no relief </li></ul></ul><ul><ul><li>Currently taking Imitrex 50mg tablet </li></ul></ul><ul><li>Nausea with migraine; vomiting occasionally after taking Imitrex tablet </li></ul><ul><li>Patient does not like injections </li></ul>
  5. 5. History of Present Illness <ul><li>Migraines occur mainly with menses, but also at other times during the month </li></ul><ul><li>(+) Floaters with migraine </li></ul><ul><li>(+) Photophobia with migraine </li></ul><ul><li>(+) Phonophobia with migraine </li></ul><ul><li>Pain scale 7 out of 10 </li></ul>
  6. 6. Past Medical History <ul><li>Chlamydia </li></ul><ul><ul><li>10/21/08: Treated with Doxycycline 100mg </li></ul></ul><ul><ul><ul><li>1 tablet PO BID x 7 days </li></ul></ul></ul><ul><li>Eczema (since childhood) </li></ul><ul><ul><li>5/19/09: Given 0.1% Triamcinolone acetonide topical cream </li></ul></ul><ul><ul><ul><li>Apply to affected area QID </li></ul></ul></ul>
  7. 7. Social History <ul><li>Denies smoking and illicit drug use </li></ul><ul><li>“ Social Drinker” </li></ul><ul><li>Lives alone; single </li></ul><ul><li>Currently in school for Early Child Development </li></ul>
  8. 8. Family History <ul><li>Breast Cancer </li></ul><ul><ul><li>Mother </li></ul></ul><ul><ul><li>Maternal grandmother </li></ul></ul><ul><ul><li>Paternal grandmother </li></ul></ul><ul><li>Multiple Sclerosis </li></ul><ul><ul><li>Mother </li></ul></ul><ul><ul><li>Sister </li></ul></ul><ul><li>Hypertension </li></ul><ul><ul><li>Mother </li></ul></ul>
  9. 9. Current Medication List <ul><li>Imitrex 50mg tablet </li></ul><ul><ul><li>1 PO PRN migraine. May repeat in 2 hours if no relief. </li></ul></ul><ul><li>Naproxen 500mg tablet </li></ul><ul><ul><li>1 PO BID PRN migraine </li></ul></ul><ul><li>Triamcinolone acetonide 0.1% topical cream </li></ul><ul><ul><li>Apply to affected area QID (for eczema) </li></ul></ul>
  10. 10. Labs (7/29/09) <ul><li>Temp: 98⁰F </li></ul><ul><li>BP: 126/74 </li></ul><ul><li>past readings: 116/90 (7/10/09) </li></ul><ul><li>121/80 (6/30/09) </li></ul><ul><li>127/80 (5/19/09) </li></ul><ul><li>Weight: 236 lbs </li></ul><ul><li>past readings: 236 lbs (7/10/09) </li></ul><ul><li>234 lbs (6/30/09) </li></ul><ul><li>236 lbs (5/19/09) </li></ul>
  11. 11. Labs (cont.) – 7/1/09 Test Procedure Result Reference Range High/Low/Normal RBC 4.43 mill/mcl 3.80-5.10 mill/mcl Normal Hgb 11.5 g/dL 11.7-15.5 g/dL LOW Hct 34.1% 35.0-45.0% LOW MCV 77.0 FL 80.0-100.0 FL LOW MCH 26.0 PG 27.0-33.0 PG LOW MCHC 33.7 g/dL 32.0-36.0 g/dL Normal Platelet Count 233 thous/MCL 140-400 thous/MCL Normal TSH 1.66 mU/L 0.40-4.50 mU/L Normal
  12. 12. Problem List <ul><li>Migraines </li></ul><ul><ul><li>Nausea </li></ul></ul><ul><li>Anemia </li></ul><ul><li>Dysmennorhea </li></ul><ul><li>Fatigue </li></ul><ul><li>Obesity </li></ul>
  13. 13. What should we recommend for TK? <ul><li>Migraines/Nausea </li></ul><ul><ul><li>Imitrex </li></ul></ul><ul><ul><ul><li>Available as an oral tablet, and injection, and a nasal spray </li></ul></ul></ul><ul><ul><ul><li>Recommend switching from Imitrex oral tablet to Imitrex 5mg/actuation nasal spray </li></ul></ul></ul><ul><ul><ul><ul><li>Use 10mg (5 in each nostril) at onset of headache. May repeat in 2 hours if needed. Do not exceed 40mg in a 24 hour period. </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>#48 sprays with 3RF </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Bridges to access program (GlaxoSmithKline) </li></ul></ul></ul></ul></ul><ul><ul><li>Also recommend switching directions of Naproxen 500mg tablet </li></ul></ul><ul><ul><ul><li>Tk 1 PO TID with food. Start 2 days before to 3 days after the start of menses </li></ul></ul></ul>
  14. 14. What should we recommend for TK? <ul><li>Migraines </li></ul><ul><ul><li>Prophylactic therapy? </li></ul></ul><ul><ul><ul><li>Group 1 –most evidence and least side effects </li></ul></ul></ul><ul><ul><ul><ul><li>Propranolol </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Timolol </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Amitrypyline </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Depakote </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Topamax </li></ul></ul></ul></ul>
  15. 15. What should we recommend for TK? <ul><li>Migraines </li></ul><ul><ul><li>Nonpharmacological Therapy </li></ul></ul><ul><ul><ul><li>Lifestyle changes </li></ul></ul></ul><ul><ul><ul><ul><li>Regular routines for eating, sleeping, and exercise </li></ul></ul></ul></ul><ul><ul><ul><li>Avoidance of triggers </li></ul></ul></ul><ul><ul><ul><ul><li>Alcoholic beverages </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Caffeinated beverages </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Chocolate </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Stress/Overexertion </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Bright Lights </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Odors </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pollution </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Eyestrain </li></ul></ul></ul></ul>
  16. 16. What should we recommend for TK? <ul><li>Anemia </li></ul><ul><ul><li>Ideally, would like to obtain a serum ferritin to confirm iron deficiency </li></ul></ul><ul><ul><li>Recommend ferrous sulfate 325 mg (65mg iron) </li></ul></ul><ul><ul><ul><li>Take 1 tablet PO TID with food </li></ul></ul></ul><ul><ul><ul><li>If constipated can use OTC colace </li></ul></ul></ul><ul><ul><ul><li>#90 with 3RF </li></ul></ul></ul><ul><ul><ul><li>Purchase OTC </li></ul></ul></ul>
  17. 17. What should we recommend for TK? <ul><li>Dysmennorhea </li></ul><ul><ul><li>The changing of directions of the Naproxen 500mg tablet for migraines serves a double purpose </li></ul></ul><ul><ul><ul><li>The naproxen 2 days prior to 3 days after onset of menses should help with both migraines and dysmennorhea </li></ul></ul></ul>
  18. 18. What should we recommend for TK? <ul><li>Fatigue </li></ul><ul><ul><li>TSH normal </li></ul></ul><ul><ul><li>Could be due to either migraines or anemia, or both </li></ul></ul><ul><ul><li>Treat anemia/migraines and monitor fatigue </li></ul></ul>
  19. 19. What should we recommend for TK? <ul><li>Obesity </li></ul><ul><ul><li>Recommend regular exercise </li></ul></ul><ul><ul><ul><li>Start with walking 10-30 minutes 3x a week and increase as tolerated </li></ul></ul></ul><ul><ul><li>Dietary Restrictions </li></ul></ul><ul><ul><ul><li>May also help with migraines </li></ul></ul></ul>
  20. 20. References <ul><li>Clinical Pharmacology. Tampa, FL: Gold Standard; 2009. http://cp.gsm.com. Updated August, 2009 . Accessed August 23, 2009. </li></ul><ul><li>“ Evidence-Based Guidelines for Migraine Headache in the Primary Care Setting: Pharmacological Management for Prevention of Migraine.” 2009. US Headache Consortium. </li></ul><ul><li>“ Evidence-Based Guidelines for Migraine Headache in the Primary Care Setting: Pharmacological Management of Acute Attacks.” 2009. US Headache Consortium. </li></ul><ul><li>Lay, Christine and Richard Payne. “Recognition and Treatment of Menstrual Migraine.” The Neurologist. 2007; Volume 13. 4:197-204. 2007 </li></ul><ul><li>“ Understanding the Prevalance of Migraines: Diagnosis, Disease, and Treatment.” APHA Special Report. 2007. American Pharmacists Association. </li></ul>
  21. 21. QUESTIONS?

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