Reason For Encounter : Routine Inr Check For Anticoagulation Therapy

933 Words Apr 1st, 2016 4 Pages
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 a lot. He has no blood in stool and no black stools.

Past medical/surgical history: He had a stroke 3 years ago due to his untreated atrial fibrillation.

Past family history: none
Social history: Alcohol:6 to 8 beers on the weekend, Caffeine: none, Tobacco: none

OBJECTIVE Background (pertinent laboratory values, physical assessment measurements, etc.)
Weight: 240 pounds
Blood pressure: 134/82 mmHg
Heart rate: 70 beats every minute
Pulse: strong, regular rate and rhythm
International normalized ratio (INR): 3.2 (today), 2 to 2.5 (previous), 2 to 3 (goal of therapy)
Immunization history: He is up-to-date with his immunizations.
Observation: He has residual right-sided weakness, for example, he is hardly open bottles and jars due…

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