Analysis: Routine Inr Check For Anticoagulation Therapy

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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
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FOR EACH CONDITION ASSESSED: include indication, goals of therapy, drug therapy problems, and therapeutic options):

INDICATION (CONDITION 1) _______Atrial fibrillation __________________

GOALS OF THERAPY (CONDITION 1) (improvement or normalization of signs/symptoms/laboratory tests or reduction of risk; must have a short- and long-term effectiveness goal: include parameter, value, time frame. Include label of “Effectiveness,” or “Other.”)

1. 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
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For anticoagulation therapy, avoid cranberry juice or products, eat approximately the same amount of vitamin K daily, not drink alcohol while taking the drug.

Follow-up Evaluation (include date, format (e.g. phone call or office visit) and what specific monitoring parameters and information will be evaluated to assess effectiveness and safety at the next contact):
One week from today in person (visit the pharmacy). Test for the INR value to see if it is within 2 to 3 (effectiveness) and evaluate for controlling the heartburn symptom (effectiveness), evaluate for side effects of warfarin such as bleeding and formation of thrombosis (safety) and evaluate for side effects of famotidine such as constipation, diarrhea, headache (safety). If any side effects happen, contact pharmacy or visit the primary care provider

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