C3.2 R5: Perform and document a “Best Possible Medication History (BPMH)”

ID: AA is a 30 yo transgender individual (prefers neutral pro-nouns; transitioning from female to male)

Medical Conditions:

  • Anorexia Nervosa, binge-purging sub-type
    • no laxative use
    • no over-exercise
    • binge eating 1-2 times/day
    • vomiting 4-5 times/day
  • Gender dysphoria
  • History of alcohol use disorder
  • History of social anxiety (denies any anxiety currently)
  • History of hyponatremia, hypokalemia, pancytopenia

Medications PTA:

  • Testosterone cypionate 0.25mL SC weekly as directed by physician
    (different from P’net: 0.1mL IM weekly as directed by physician)
  • Trazodone 50mg PO HS PRN
    • uses “infrequently” for insomnia (difficulty falling and maintaining sleep)
    • Effective and helps her fall asleep within 30 minutes
    • No side effects or concerns with medication
    • 50 tablets last filled on April 4, 2016
  • Gabapentin 300mg PO TID
    • No longer taking
    • Was taking for alcohol use disorder (Last drink 6 months ago)
  • Takes ibuprofen as needed for dental pain
  • No other non-prescription, NHP or supplements

Social history:

  • Smoker: Smokes 1/2 pack of cigarettes per day – no thoughts of quitting and plans to continue smoking after discharge
  • Alcohol: used to drink “excessively”, with last drink being 6 months ago
    • However, after quitting binging and purging worsened
  • IVDU: on Dec 8, used cocaine once – had a withdrawal seizure
  • Occupation: Previously barber and worked in a brewery
  • Finance: Lives on income assistance

 

 

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