Student Name: Angela McGarvey SOAP note population: Geriatrics SOAP note #: 3 Clinical location/Preceptor: Dothan Medical Associates/ Dr. Walter Doty III Date of patient encounter: 11/7/18 Patient identifier:07A Patient age: 66 Ethnicity: Caucasian Gender: Male S: Subjective Data: Chief Complaint (CC): “I would really like to change my diabetic medicine”. HPI: RL is a pleasant, 66-year-old Caucasian male who presents to the clinic for his yearly physical. change his diabetic mediations due to the shots causing bruising from his Warfarin therapy. Reports he noticed 3 weeks ago, that he has several bruises all over his body from is diabetic shots. Denies any changes in his diabetic needles. His medications have not been changed recently. Reports his last PT/INR was checked last week and it was 2.9. He has no blood in his stool. PMH: HTN (2009) I10 well controlled with meds DM II with Peripheral Neuropathy (2010) E11.21 well controlled with meds by Sleep Apnea with CPAP (2013) G47.33 well controlled with Cpap machine settings Prostate Cancer (2004) Z85.46 chemotherapy (2005) in remission, followed by Dr. Patel Paroxysmal Atrial Fibrillation (2014) I48.0 Well controlled with meds. Followed by Dr. Aliabadi Rheumatoid Arthritis (2005) M06.9 well controlled with meds Presence of cardiac pacemaker Z095.0 Current settings controlled by Dr. Aliabadi PSH: 1. Single chamber pacemaker placement with AV node ablation for a-fib (2014) no complications. 2. TURP (2005) no complications, 3. Right Total Knee Replacement (2011) no complications, 4. Lap Cholecystectomy (2002) no complications. Past hospitalizations: 1. Pacemaker placement and ablation (2014) Pt tolerated procedure well with no complications. Adult Immunizations/Preventative Screening: Shingles: denies Flu Vaccine: October 2018 Pneumococcal Vaccine 13: October 2017 Pneumococcal Vaccine 23: Denies Tetanus: 2011 Blood Pressure Screening (Oct 2018-cardiology) Dental Exam (Jan 2018) Eye Exam (March 2018) Testicular Exam (Oct 2018) Colonoscopy (June 2016) Prostate Exam (Oct 2018) Diabetes Screening (June 2018) Alcohol Misuse (Oct 2018) Depression (Oct 2018) Lipid Profile Screening (Oct 018) Current Health Status: 1. Allergies: No known food, environment, or medication allergies. 2. Tobacco- Denies current or past tobacco use 3. Alcohol Use- Drinks 1-2 beers a year x 40 years 4. Illegal Drugs: Denies current or past drug use 5. Current Medications: Warfarin 2.5mg M, W, F and 5mg T, TH, Sat. (2014- a-fib). Gabapentin 100mg PO BID (2010- diabetic neuropathy). Lisinopril 10mg PO Daily (2009- HTN) Lantus 70/30 40 units SQ BID (2010- DM II) Aleve OTC prn (Rheumatoid arthritis, many years). 6. Environmental hazards: Pt worked outdoors as a mechanic for 20 years and continues to garden for 40 years, exposure to the sun for long periods of time could make him at higher risk for skin cancer. 7. Safety measures employed on a regular basis: Pt wear seat belt while driving and has smoke detectors in home and firearms stored in secured safe. 8. Exercise and Leisure: Pt likes to go to garage sales on the weekends with his wife. Reports gardening is his exercise. 9. Sleep: Pt has no problems going or staying asleep. Sleeps on his side and uses 3 pillows. Sleeps 8-9 hours each night. 10. Diet: 24 hour Breakfast o 1 cup coffee (6 oz) black o 1 piece of toast with butter o 2 scrambled eggs Lunch o Peanut butter sandwich o Bbq chips o Diet coke (7.5 oz) Dinner o Country fried steak with gravy o Mashed potatoes o Carrots (steamed) o Cornbread with butter o Sweet tea (15 oz) FH: Father- died at 67 with lung cancer Mother died at 61 with heart attack Brother- age 59 PAD (10 years) Sister – age 62 Diabetes (15 years) Daughter- 35 Diabetes (5 years) Son- 30 Hyperlipidemia (4 years) Paternal Grandfather- died at 69 of heart attack Paternal Grandmother- died at 80 with Alzheimer’s (10 years) Maternal Grandfather- died at 86 with Prostate cancer (5 years) Maternal Grandmother-died at 90 with Breast Cancer (2 years) Maternal Uncle- age 85- Hypertension (10 years) Family Risk Analysis SH: RL is married and lives at home with his wife. Patient has one brother and sister along with one daughter and son. Patient lives in Dothan, AL. Patient graduated high school and immediately went into the military. He is retired from the United States Air Force for 25 years and was a machinist. Religious preference is Methodist. RL’s primary insurance is Tricare for Life. He denies concern with cost of care. He denies any recent travel. Patient reports he is heterosexual and only one lifetime partner and that is his wife. Erikson’s Stage: Ego Integrity vs. Despair. Patient states that he is satisfied with his life and his accomplishments. He is proud of his service in the military and would not change anything about his life. ROS: Constitutional Symptoms: Denies generalized health problems; weight loss; fever; recent infection or change in activity level. Eyes: Denies vision problems, poor eyesight, double vision, blurred vision, redness, drainage, excessive tearing, pain, or trauma. Pt reports last eye exam was within one year, no change in prescription. Wears trifocal lenses and glasses were last adjusted at optomologist appointment in March 2018. . Ears, Nose, Mouth and Throat: Ears: Denies problems including, presence of infection or pain, vertigo, use of assistive hearing device. Nose: Patient denies issues with sense of smell, discharge, obstruction, epistaxis, sinus trouble. Mouth and teeth: RL had a dental appointment last month at which time he was re-fitted for dentures as his previous set was ill-fitting. RL reports brushing once daily and nightly use of Efferdent to clean his dentures overnight. Pt denies issues with bleeding of gums, problems with sense of taste, mouth odor or ulcers, or sore tongue. Throat: Patient denies sore throat, hoarseness, dysphagia. Cardiovascular: Denies any current cardiac issue, abnormal heart sounds, chest pain, palpitations, high or low blood pressure, edema, claudication or varicose veins. Respiratory: Denies cough, previous TB exposure, difficulty breathing, wheezing, hemoptysis, sputum production or night sweats, or dyspnea on exertion. Gastrointestinal: Denies issues with nausea, vomiting, food aversion, diarrhea, abdominal pain, flatulence, change in bowel pattern, black/bloody stools, hemorrhoids, jaundice or rectal pain. Denies constipation. Genitourinary: Denies nocturia, dysuria, discharge, pain, incontinence, or problems with the penis and testes. Musculoskeletal: Denies neck pain or stiffness, or swelling, incapacitating back pain, paralysis, deformities, changes in range of motion of activity, or injury. Reports occasional joint pain in the hands and hips from his rheumatoid arthritis “reports this is normal for him” that is relieved with OTC Aleve. Integumentary: Denies noticing lumps, pain, discharge, or dimpling anywhere on the skin, changes in skin, rash, itching, nail deformity, hair loss, new moles, open areas. Reports easy bruising related to self-injection sites. Neurologic: Denies muscle weakness, dizziness, syncope, stroke, seizures, paresthesias, involuntary movements or tremors, loss of memory, severe headaches. Reports neuropathy is not self-limiting and is well-controlled with oral Gabapentin. Psychiatric: Denies nightmares, mood changes, depression, anxiety, nervousness, insomnia, suicidal thoughts, potential for exposure to violence. Pt reports feeling safe at home. Endocrine: Denies thyroid problems, cold or heat intolerance, polyphagia, polyuria, changes in skin, hair or nail texture, unexplained weight change, changes in facial or body hair, change in hat or glove size, use of hormonal therapy. Labs Oct 2018- FSBS 110, HgbA1c 7.2% Hematologic/Lymphatic: Denies unusual bleeding, history of anemia, history of blood transfusions, swollen and/or tender glands. Reports bruising “from that Warfarin.” Denies any blood in stools or bleeding from gums. October 2018 INR 2.9. Allergic/Immunologic: Denies seasonal allergies; no previous allergy testing. Flu and pneumonia vaccine were received October 2018. O: OBJECTIVE DATA: Constitutional – RL is a pleasant, well-dressed male who is sitting on the exam table. VS: BP 110/70 Left arm sitting with adult cuff, HR 86, Temp 97.5 oral, RR 18, SPO2 98% on RA, height 75”, weight 269.5lb BMI 33.7 obese. Head, Eyes, Ear, Nose, Throat, Neck: Head: Normocephalic, atraumatic, no visible palpable masses, or scarring. Hair evenly distributed .PERRLA, EOM intact, red reflex is present upon examination, no hemorrhage or exudate noted bilaterally. External ears are normal bilaterally. TMs are easily visualized, intact and pearly grey bilaterally. No bulge, erythema or exudate noted. Hearing is present and WNL bilaterally. External nose/nares are normal bilaterally without lesion or deformities noted upon inspection. Nasal mucosa and turbinates are clear bilaterally, septum is midline. Teeth are absent, dentures are in place and fit well. Tongue and uvula are midline, posterior pharynx is clear, pink and without erythema or exudate. Negative for halitosis. Neck: No noticeable or palpable swelling. No meningeal signs including nuchal stiffness. Unable to appreciate thyroid gland upon palpation. Cardiovascular: S1 and S2 are present bilaterally. Regular rate and rhythm with no murmur, rub or gallop appreciated. PMI is mid clavicular line, 5th ICS. No JVD present, no carotid bruit present. Capillary refill 2-3 seconds, +2 pedal pulses bilaterally. Respiratory: Lungs are clear to auscultation bilaterally throughout all lung fields, anterior and posteriorly. No use of accessory muscles, no adventitious lung sounds noted. Gastrointestinal: Abdomen is soft, round, obese, non-tender and non-distended. Bowel sounds present x4 quadrants. Light and deep palpation are without guarding or rebound tenderness. Liver edge, spleen and kidneys not felt. Liver span 10cm by percussion. I was unable to appreciate any masses upon deep palpation. Genitourinary: Deferred today. Last PSA (4.0) was done in Dr. Patel’s office in June of this year. Patient is followed there for history of prostate cancer. Musculoskeletal: Normal ROM, strength and grips equal bilaterally. Patient is able to lie down and sit up from the exam table without difficulty. No swelling, erythema or crepitus noted to joints. Spine is midline. Negative straight leg raise. Integument: Skin is supple and intact. No rashes, lesions, subcutaneous nodules, indurations or ulcerations noted. No nail bed clubbing, peripheral/central cyanosis, or petechiae noted. Multiple bruises of different sizes and shapes ranging from 1mm to 3mm scattered on back of arms bilaterally and front of bilateral thighs in different stages of healing. Neurologic: Alert and oriented x3. Short and long term memory intact. No tremors or involuntary movements. Cranial Nerves: I Olfactory-Identifies correct smells II Optic - Corrected visual acuity 20/20 bilaterally, visual fields full; optic disc sharp with venous pulsations present bilaterally. III-oculomotor, IV- trochlear, VI- abducens- pupils 4mm and reactive to light, extraocular movements intact; no ptosis. V trigeminal- Facial sensation equal to pinprick in all 3 divisions bilaterally. VII Facial - Face symmetric with normal eye closure and smile. VIII Vestibulocochlear- Hearing normal to rubbing fingers. IX Glossopharyngeal, X Vagus- Palate elevates symmetrically; phonation is normal. XI Accessory- shoulder shrug equal bilaterally. XII Hypoglossal -Tongue midline with good movements and no atrophy. Motor- Normal bulk, tone, and strength noted to bilateral upper and lower extremities, no pronator drift. Sensory- Vibration felt in toes and fingers bilaterally; pinprick intact in feet without distal gradient. Reflexes- 2+ and symmetric at biceps, triceps, knees, and ankles; plantar responses flexor bilaterally. Coordination- normal fine finger movements, finger-nose-finger, and heel-kneeshin. Gait- Steady with normal steps, base, arm swing, and turning; normal heel, toe and tandem walking. Psychiatric: Judgement is appropriate for the patient, mood and affect are appropriate. No obvious depression, anxiety or agitation. Hematological/Immunologic/lymphatic: Negative for petechia or abnormal bleeding. Noted throughout entire body. Multiple bruises, see integumentary No cervical, post-auricular, clavicular, or inguinal lymphadenopathy noted. DIAGNOSTIC TESTING: Blood glucose (82962) and Hemoglobin A1c (83036) - to evaluate effectiveness of patient’s current medication regimen (Resulted 180 fasting Blood sugar and 7.2 A1c. INR (85610) - To evaluate therapeutic effect of Warfarin (pending). CBC with differential (85007)- Routine for annual screening examination (pending). CMP (10231) - Routine for annual screening examination, also evaluate renal function in the patient with known diabetes who chronically uses NSAIDs for arthritis pain. Calcium, magnesium and phosphorus levels are may be altered in the patient with cardiac history and history of chemotherapy. (pending) Lipid profile (80062) - Routine for annual screening examination (pending). TSH (35267) - Routine for annual screening examination and to evaluate thyroid function in the elderly patient (pending). Obtain baseline EKG (93042) from cardiology office- for PMD record (received) C-Peptide ( 8046) to evaluate if patient is truly a type II diabetic (pending). A: ASSESSMENT/ANALYSIS: Level of Visit: Level 4 -99214 DIFFERENTIAL DIAGNOSES 1. Z00.01- Encounter for routine adult medical examination with abnormal findings. o Supportive- AgbA1c is 7.2 2. Z01.419- Encounter for Gynecological exam. o Refuted- male sex 3. Z71.89- Encounter for travel physical o Refuted- patient not traveling. 4. D68.32- Hemorrhagic disorder due to extrinsic circulating anticoagulants o Supported- excessive bruising 4. R23.3- Spontaneous ecchymosis o Refuted- patient on anticoagulant 5. D68.9- Coagulation defect o Refuted- Patient is known to be on an anticoagulant DEFINATIVE DIAGNOSIS Z00.01- Encounter for routine adult medical examination with abnormal findings. D68.32- Hemorrhagic disorder due to extrinsic circulating anticoagulants ORGANIZED LIST: 1. Acute self-limited problems Bruising- M79.81 2. Chronic health problems HTN – I10 o Medication- Lisinopril 10mg by mouth daily o Treatment- ACE inhibitor o Education Reduce sodium intake to no more than 100mmol/day weight loss limit alcohol intake to no more than 0.5oz of ethanol per day maintain adequate intake of dietary potassium maintain adequate of calcium and magnesium for general health stop smoking Engage in aerobic exercise at least 30 minutes daily for most days Monitor blood pressure readings at home Common Side effects of medication dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position blurred vision unusual tiredness or weakness o Diagnostic- CMP o Follow-up- 4 weeks for evaluation of medication adherence and assess for need for medication adjustments. Notify healthcare provider sooner if you experience any side effects, chest pains or SOB. DM II with peripheral neuropathy- E11.21 o Medication- Metformin ER 500mg by mouth twice a day o Treatment- Biguanides o Education Monitor blood sugar daily Common side effects of this medication are nausea diarrhea hypoglycemia abdominal cramping o Diagnostic- Blood glucose, Hemoglobin A1c, and C-Peptide Follow-up- Follow-up- 4 weeks for evaluation of medication adherence and assess for need for medication adjustments (As a nurse practitioner I would bring patient back in 1 week). Notify healthcare provider sooner if experiencing any side effects or problems. Rheumatoid Arthritis- M06.9 o Medication- Aleve 500mg by mouth every 12 hours as needed for pain o Treatment- Nsaids o Education Common side effects include: stomach bleeding, kidney damage, and hypertension o Follow-up- 4 weeks for evaluation of medication adherence and assess for need for medication adjustments. Obstructive Sleep Apnea with CPAP- G47.33 o Medication- None o Treatment- Cpap machine o Education Make CPAP part of your bedtime routine. Make small adjustments to increase your level of comfort. Make sure your mask is a good fit. The most common problems with CPAP occur when the mask does not fit properly. Use a saline nasal spray to ease mild nasal congestion. Schedule a regular time to clean your equipment. o Follow-up- 4 weeks A-fib (rate controlled)- I48.0 o Medication- None o Treatment- Pacemaker with ablation o Education Report any of these symptoms to your PCP or Cardiologist dizziness, fainting spells, or trouble catching your breath swelling, fluid, warmth, pain, or redness (or other unusual colors) at the pacemaker site chills or a temperature of 100.5[degrees] F or higher pain in your chest or a feeling that a muscle is twitching near your heart hiccups that last more than 15 minutes weight gain of more than 3 pounds (1.4 kg) in 2 days or less swelling in your hands, feet, or arms palpitations or a feeling that your heart is beating too fast a heart rate that is 5 to 10 beats less than your programmed rate. o Follow-up- 4 weeks or sooner if any problems arise. Obesity- E66.9 o Medication- None o Treatment- Healthy diet and 30 minutes of cardio exercise 3-4 days a week o Education Don't skip meals — this may lead to overeating later. Weight loss efforts are most successful when meals and snacks are small and spread out during the day. Eat balanced meals. Choosing a wide variety of foods is important for good health, but control portion sizes and avoid second servings. Limit foods that are high in saturated fat, since fat is a concentrated source of calories. Try making exercise a daily habit. Aim for at least 30 minutes of moderate activity, such as brisk walking, on most days of the week. If your goal is to lose weight, however, you'll benefit from doing more, as much as 60 to 90 minutes of activity per day. Don't set the bar too high when you're just getting started. Start slowly, and gradually increase your daily activity level. o Follow-up- 4 weeks or sooner if any problems arise 3. Health maintenance Nutritiono Choose a diet low in fat, saturated fat, and cholesterol o Choose a diet with plenty of vegetables, fruit, and grain products o Use sugars in moderation o Use salt and sodium in moderation o If you drink alcoholic beverages, do so in moderation Weight loss o Follow a healthy diet, and if you are overweight or obese, reduce your daily intake by 500 calories for weight loss o Stay physically active o Limit the time you spend being physically inactive Exercise o Exercise in water such as swimming and/or hydro classes are excellent activities that provide a cardiovascular or resistance workout while supporting the body weight o Begin exercising for 10 minutes or less and when the patient feels comfortable increase the exercise duration to 11 minutes, then 12 and so on until the desired recommended times are achieved Vaccinationso Influenza (Flu): Yearly flu vaccine o Zoster (Shingles): Vaccine for adults at age 60 o Pneumococcal (Pneumonia): At least two vaccinations (injections) one year apart beginning at age 65 o Tdap/Td (Tetanus, Diphtheria and Pertussis/Tetanus and Diphtheria): Every 10 years. P: Plan: Z00.01- Encounter for routine adult medical examination with abnormal findings 1. Diagnostics1. Blood glucose (82962) and Hemoglobin A1c (83036) 2. INR (85610) 3. CBC with differential (85007) 4. CMP (10231) 5. Lipid profile (80062) 6. TSH (35267) 7. Obtain baseline EKG (93042) 8. C-Peptide (8046) 2. Treatment Medications- Metformin o Diabetes Mellitus Type 2 MOA- Decreases hepatic glucose production, decreases intestinal absorption of glucose, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization. Usual Dosage- 500mg my mouth twice a day Availability Generic Name: Metformin Brand Names: Fortamet, Glucophage, Glucophage XR, Glumetza. Riomet Cost- Generic Metformin Publix (Dothan, Al)- Free, 30-day supply Winn-Dixie (Dothan, Al)- $3.00 for a 30-day supply Wal-Mart (Dothan, Al)- $4.00 for a 30-day supply Diagnosis specific treatment o Exercise or specific activities Aerobic – walking, jogging/running, tennis basketball, swimming or biking for 30 minutes or longer 3 days a week Strength Training- lifting weight for 20-30 minutes at least 23 times a week Flexibility training- stretching exercises 2-3 times a week o Diet or diet modifications Foods to eat for a type 2 diabetic diet include complex carbohydrates such as brown rice, whole wheat, quinoa, oatmeal, fruits, vegetables, beans, and lentils. Foods to avoid include simple carbohydrates, which are processed, such as sugar, pasta, white bread, flour, and cookies, pastries. o Home Monitoring/treatment Daily glucose checks Daily blood pressure checks Diabetic diet 3. EducationHealth Promotiono Implement combined diet and physical activity promotion programs to prevent type 2 diabetes for people at increased risk. These can include counseling, coaching, or a combination of both. o Develop case management interventions to coordinate and provide healthcare for all people affected by diabetes. o Engage community health workers in diabetes prevention programs to improve glycemic control and weight-related outcomes for people at increased risk for type 2 diabetes. o Develop intensive lifestyle interventions for patients with type 2 diabetes to improve glycemic control and support dietary modification, regular physical activity, and weight management. o Develop team-base care interventions to help patients manage type 2 diabetes and improve blood glucose, blood pressure, and lipid levels. Health Maintenance/safety Issueso A1c- target < 7% or lower if not having significant hypoglycemia o Blood pressure - target < 130/80 o Foot exam and foot care o Fitness plan/ways to be active o Stress management o Keep daily blood sugars within normal range Signs and symptoms of hyperglycemia Increased thirst Headaches Trouble concentrating Blurred vision Frequent peeing Fatigue (weak, tired feeling) Weight loss Blood sugar more than 180 mg/dL Signs and symptoms of hypoglycemia Confusion Dizziness Feeling shaky Hunger Headaches Irritability Pounding heart; racing pulse Pale skin Sweating Trembling Weakness Anxiety Disease Preventiono Watching your weight o Eating healthy o Staying active 4. Consultation/ Referrals None at this time. 5. Follow-upSpecific Instruction 1. 4 weeks for evaluation of medication changes (as a Nurse Practitioner I would bring the patient back in a week) 2. If patient experiences hypoglycemia or hyperglycemia, notify the healthcare professional immediately. Acute Problems 1. If daily Blood Sugars and A1c levels do not remain in therapeutic range, may need to refer to Endocrinologist. Chronic Health Problems 1. Maintain regular scheduled appointments with Dr. Doty (PCP) for management of Hypertension, DM2, sleep apnea and rheumatoid arthritis. 2. Maintain regular scheduled appointments with Dr. Aliabadi (Cardiologist) for management of A-Fib and Pacemaker. 3. Maintain regular scheduled appointments with Dr. Patel (Oncologist) for management of Prostate Cancer. 6. Other interventions specific to the patient/situation1. None at this time D68.32- Hemorrhagic disorder due to extrinsic circulating anticoagulants 1. Diagnostics1. Blood glucose (82962) and Hemoglobin A1c (83036) 2. INR (85610) 3. CBC with differential (85007) 4. CMP (10231) 5. Lipid profile (80062) 6. TSH (35267) 7. Obtain baseline EKG (93042) 8. C-Peptide (8046) 2. Treatment1. Medications- Discontinued Warfarin 2.5mg M, W, F and 5mg T, TH, Sat. Indication for this patient- Patient had a history of uncontrolled A-fib until 2014 when a pacemaker and ablation were performed. Up until then he was put on anticoagulation therapy which was causing excessive bruising from his diabetic shots. MOA- Warfarin competitively inhibits the vitamin K epoxide reductase complex 1 (VKORC1), which is an essential enzyme for activating the vitamin K available in the body. Through this mechanism, warfarin can deplete functional vitamin K reserves and therefore reduce the synthesis of active clotting factors. Usual Dosage- 2-5mg by mouth daily for 2 days, then check PT/INR and adjust dosage depending on results. Availability- generic (Warfarin) Brand name (Coumadin, Jantoven) Based on the 5mg dosage (Warfarin) Wal-Mart- Dothan, AL $4.00 for a 30 day supply Winn-Dixie- Dothan, AL $4.00 for a 30 day supply Publix Dothan, AL $7.50 for a 30 day supply 2. Diagnosis specific treatment Exercise Stroke Prevention Any amount of exercise will help, but if you can manage it, you should aim to do at least 30 minutes of moderate physical activity five or more times a week. You don’t have to do all 30 minutes at once, it can be broken up into smaller blocks of time throughout the day. You can choose any form of exercise as long as the activity increases your heart rate and makes you feel warm and a little out of breath. DVT Prevention Exercise your legs frequently while you’re sitting Exercise regularly (goal: at least 30 minutes of moderate aerobic exercise, 5-days per week) Get up and walk around every 2 to 3 hours Diet or diet modifications Stroke Prevention Reduce the salt in your diet to no more than 1,500 milligrams a day (about a half teaspoon). Avoid high-cholesterol foods, such as burgers, cheese, and ice cream. Eat 4 to 5 cups of fruits and vegetables every day, one serving of fish two to three times a week, and several daily servings of whole grains and low-fat dairy. DVT Prevention Foods that are rich in vitamin E or omega-3 fatty acids (both of which have blood thinning properties and may reduce the risk of blood clots): Sources of omega-3 fatty acids include: Fatty fish (i.e. anchovies, salmon, lake trout, herring, mackerel) and fish oil Plant sources (i.e. flaxseed, sunflower seeds, canola oil, corn oil, safflower oil, soy) Vitamin E rich foods include: Nuts (i.e. walnuts, almonds, hazelnuts) Vegetable oils (i.e. canola oil, sunflower oil, palm oil) Lentils (i.e. chickpeas) Oats and wheat Educate patient that he no longer has to adhere to a Warfarin diet and that he may include green-leafy vegetables in his diet. Home monitoring/treatment Signs and symptoms of stroke weakness on one side of the body numbness of the face unusual and severe headache vision loss numbness and tingling unsteady walk Signs and symptoms of DVT Swelling in one or both legs Pain or tenderness in one or both legs, even if it's just when you stand or walk Warm skin on your leg Red or discolored skin on your leg Veins that are swollen, red, hard, or tender to the touch you can see Signs and symptoms of Pulmonary embolism Sudden shortness of breath Chest pain-sharp, stabbing; may get worse with deep breath Rapid heart rate Unexplained cough, sometimes with bloody mucus Prevention of excessive bleeding Use a soft bristle toothbrush Shave with an electric razor rather than a blade Use caution when handling sharp objects (shaving razors, knives) Avoid activities that could result in injury (eg, contact sports) Use appropriate safety equipment (eg, helmets, padding) during physical activity Avoid aspirin or other non-steroidal anti-inflammatory agents (NSAIDS) (eg, ibuprofen [sample brand names: Advil, Motrin] and naproxen [sample brand name; Aleve]) unless your healthcare provider tells you to take them. Other non-prescription pain medications, such as acetaminophen, may be a safe alternative. 3. Education1. Health Promotion a. Lifestyle changes, such as increasing physical activity, need to be tailored to each individual, with consideration of stroke-related deficits. b. Interventions with stroke survivors to increase awareness of risk and manage risk factors over the long term, such as education, written materials, behavior modification, and stroke nurse specialist follow-up, have shown modest effects. c. Empowering patients to succeed in goal-setting around healthy lifestyle choices has proven to be an effective strategy. 2. Health Maintenance/safety issues a. Strengthening leg muscles and balance through exercise b. Wearing flat, wide-toed shoes c. Eating calcium-rich foods and taking calcium supplements to increase bone strength if necessary d. Following your therapists’ recommendations about limitations and walking needs e. Not relying on furniture for support while walking. Use assistive devices prescribed by your therapist f. Recognizing that certain medicines may make you drowsy and taking precautions g. Limiting walking when distracted h. Never walking without prescribed aids such as braces or canes 3. Disease Prevention a. Lower Blood Pressure b. Stay away from smoking c. Manage your heart rhythm d. Limit alcohol e. Control your diabetes f. Exercise g. Eat healthy h. Watch cholesterol i. Keep sleep apnea under control j. Medication compliance k. Aspirin a day 4. Consultation/Referrals1. None at this time. 5. Follow-upSpecific Instructions Recheck PT/INR in 4 weeks (as a Nurse Practitioner I would bring patient back in a week) Acute Problems Educate patient if bruising or bleeding gets worse, notify the health care professional immediately. Educate patient if he has any signs or symptoms of stroke, DVT, or pulmonary embolism call 911 immediately. Chronic Health Problems Maintain regularly scheduled appointments with Dr. Doty (PCP) for management of Hypertension, DM2, sleep apnea and rheumatoid arthritis. Maintain regularly scheduled appointments with Dr. Aliabadi (Cardiologist) for management of A-Fib and Pacemaker. Maintain regularly scheduled appointments with Dr. Patel (Oncologist) for management of Prostate Cancer.