Anticoagulation Therapy Case Study

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REASON FOR ENCOUNTER: Routine INR check for anticoagulation therapy.

SUBJECTIVE Background (Description and history of the present illness or medical condition including previous approaches to treatment and responses; include other medical problems, medication experience per patient, drug allergies, current meds, etc.)

Medical conditions: HA is a 60-year-old white male with three conditions, atrial fibrillation, hypertension and gastroesophageal reflux disease. His atrial fibrillation and hypertension are controlled by medications. But he began the onset of worse heartburn 7 days ago which he believed was triggered by stress, he tried 20 mg omeprazole capsules in the morning to treat, he also tried sleep on three pillows which did not help
…show more content…
Effectiveness: [Include a short-term time-bound efficacy goal]
Decrease the INR from 3.2 to between 2 to 3 in one week.
2. Effectiveness: [Include a long-term time-bound efficacy goal]
Decrease blood pressure to less than 140/90 mmHg indefinitely.
Maintain regular rate (less than 90 beats every minute) and normal sinus rhythm indefinitely.
Maintain the INR between 2 to 3 indefinitely.
3. Other: [Include any other pertinent goals as needed]

DRUG THERAPY PROBLEMS to be resolved (CONDITION 1) (Select one of the seven major categories, and elaborate with the cause. Tie DTP to condition/drug)
Safety-adverse drug reaction-drug interaction between omeprazole and warfarin

None at this time
Therapeutic Options (to resolve the drug therapy problem(s)) (CONDITION 1) [List at least two: these can be classes or agents, or non-drug therapeutic options if applicable]
1. Famotidine, 20mg tablet.
2. Nizatidine, 150mg capsule.
**Repeat above assessment for condition 2, 3, 4, etc. as appropriate**

PLAN
Pharmacotherapy (Includes new and continuing drug therapies and changes/discontinuations with rationale)
MEDICATIONS
(DRUG PRODUCT, STRENGTH, DOSAGE FORM)
DOSAGE INSTRUCTIONS
(DOSE, ROUTE, FREQUENCY, DURATION)

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