XXXXXX
DOB: xx/xx/xxxx
Name:
DOB:
Age: Gender: Male/Female.
Drug: Pradaxa
Brief Summary: XXXX with a history of atrial fibrillation, coronary artery disease and three
coronary artery bypass surgery was on Aspirin and Plavix. He was diagnosed with iron deficiency
anemia secondary to erosive gastritis caused by the use of Aspirin, Plavix and Aleve on
05/18/2009. He was started on Protonix on 06/10/2009, 12 hours apart from Plavix. As on
08/20/2009, he was on Coumadin therapy and his INR was managed by anticoagulation clinic. As
per available pharmacy records, he was started on Pradaxa on 05/26/2011. He presented with
chest pain and shortness of breath to the emergency room on 12/10/2011 and was diagnosed with
GI bleed and anemia at the age of XX years and was hospitalized. He was asked to discontinue
Pradaxa for several weeks. He was also diagnosed with non ST elevation myocardial infarction
caused by his severe anemia. He was discharged on 12/16/2011 with Aspirin and Omeprazole. He
was started on Pantoprazole on 12/22/2011. As per pharmacy records, he was on Plavix on
02/13/2012.
Pharmacy records: 2011
Name of the Pharmacy: Unavailable.
Name of
Medication Used
Pradaxa
Dates of Use
05/26/2011, 08/04/2011 and
10/12/2011
(Quantity: 180) (Pg 167)
Name of prescribing Health Care
Provider
XXXX, MD and XXXX, MD (Pg 173)
Missing Medical Records:
What
Records/Bills
are Needed
Hospital/
Medical
Provider
Date/Time
Period
Why we need the
records/bills?
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Is Record Missing
Confirmatory or
Probable?
Hint/Clue that records are
missing
XXXXXX
DOB: xx/xx/xxxx
Medical Chronology
DATE
07/30/2009
PROVIDER
Cardiology
Center
XXXX, MD
OCCURRENCE/TREATMENT
Significant medical history:
Past medical history:
Past surgical history:
Family history:
Social history:
Allergy:
Cardiac follow up visit:
Patient complained of fatigue and tiredness.
EKG showed atrial flutter. In the view of his onset of new atrial flutter, I will admit
the patient for anticoagulation treatment.
07/11/2011
Cardiology
Center
10/12/2011
Cardiology
Center
05/26/2011
10/12/2011
12/10/2011
XXXX
Pharmacy
Reviewer’s comment: (Admission and anticoagulation treatment medical records for
treatment of atrial fibrillation are not available)
Office visit to review 24-hour Holter monitor:
HPI:
The patient states that he has had occasional dizzy spells. He denies anything
suggestive of arrhythmic syncope.
Current medications: Vytorin, Pradaxa, Plavix 75mg daily, Metformin, Amaryl,
Hyzaar, Coreg and multivitamins.
Plan: He has a class II indication for pacemaker, as there is no convincing connection
between his nonspecific dizzy spells and bradycardia.
Office visit for arrhythmia:
HPI:
The patient has conduction system disease, sick sinus syndrome and paroxysmal atrial
fibrillation. He has had no symptoms of transient ischemic attack or stroke, but
notices excessive bruising and bleeding, even from trivial injuries. He is not aware of
any melena or hematochezia.
Current medications:
Coreg, multivitamins, Plavix, Metformin, Amaryl, Pradaxa 150mg twice daily,
Vytorin and vitamins.
Assessment:
His risk of bleeding is high. He has asymptomatic atrial flutter and has AV
conduction delay.
Recommendations:
He will reduce the dose of Pradaxa to 75mg twice daily in order to reduce the risk of
bleeding.
He will discontinue his Plavix and start baby Aspirin a day.
No attempt at rhythm control is indicated, given the absence of symptoms.
A 1-week event monitor will be obtained prior to his next visit in 3 months.
He will report any presyncope or syncope immediately. At some stage he will
probably need a pacemaker.
Pharmacy bills for Pradaxa 150mg capsule:
Dates of refill: 05/26/2011, 08/04/2011, 10/12/2011
Regional
Hospital
Emergency room visit for chest pain and breathing problem:
HPI:
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103
92-93,
159-160
90-91
167
23-30
XXXXXX
DATE
PROVIDER
XXXX, MD
12/16/2011
XXXX, MD
12/16/2011
XXXX, MD
DOB: xx/xx/xxxx
OCCURRENCE/TREATMENT
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The patient has come in for chest pain and shortness of breath. He started having these
symptoms on Monday. The last chest pain lasted intermittently until Tuesday and then
resolved. It was in his lower chest with no radiation. The shortness of breath (SOB) at
first was exertional but over the last few days has been more constant. He denies any
fevers, chills, cough, sputum production, abdominal pain and syncope. He has noted
some darker stools in the last one week.
Review of systems:
 Respiratory: Positive for SOB.
 Cardiovascular: Positive for chest pain.
 Gastrointestinal: Positive for melena.
 Neurology: Light headed at times.
Current medications:
Aspirin 81mg, Plavix 75mg, Pradaxa 75mg, Dronedarone Hcl, Vytorin, Glimeperide,
Metformin.
Discontinued medications:
Coumadin, Hyzaar, Protonix, Warfarin.
Physical exam:
Genitourinary: Guaiac positive stool. No melena or bright red blood
All other systems are within normal limits.
Lab reports:
 Hemoglobin: 5.7g/dl (Low)
 Hematocrit: 19.1% (Low)
 PT: 15.3 (High)
 INR: 1.5
 aPTT: 33.3 (High)
ED course and medical decision making:
Patient typed and crossed for 4 units of packed red blood cells (PRBCs) and 3 unit
transfusion ordered. Protonix 40mg IV ordered.
Patient admitted with consult to Dr. XXXX for GI.
Disposition: Admit.
Final impression: GI bleed, anemia and shortness of breath.
Colonoscopy to cecum report for melena and iron deficiency anemia:
Impression:
 Diverticulosis entire examined colon.
 Tortuous colon.
 Internal hemorrhoids.
Recommendations:
Return patient to hospital ward for ongoing care. To visualize the small bowel,
perform video capsule endoscopy at appointment to be scheduled. Continue PPI once
daily. Okay for Aspirin and discharge later today. Hold Coumadin and Pradaxa for
several weeks.
Discharge summary:
Admission diagnoses:
 Anemia.
 Gastrointestinal bleed.
Discharge diagnoses:
 Gastrointestinal bleed of unknown source.
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20-22
XXXXXX
DATE
PROVIDER
DOB: xx/xx/xxxx
OCCURRENCE/TREATMENT
 Non-ST elevated myocardial infarction.
 Anemia of blood loss and iron deficiency.
 Atrial fibrillation.
 Adult-onset diabetes mellitus.
Laboratory Data:
Hemoglobin the day before discharge was 9.5, WBC 5.8, and platelets 208,000.
Discharge medications:
Omeprazole 20mg, Hyzaar, Carvedilol, multiple vitamins- minerals, Vytorin,
Glucophage, Metformin, Aspirin 81mg (delayed response tablet), Amaryl.
Medication stopped:
Dabigatran (Pradaxa) 75 mg per oral capsule
Brief Description of Injury: Patient was on Pradaxa from 05/26/2011. He was diagnosed with
GI bleed and anemia on 12/10/2011 and asked to discontinue Pradaxa on the same day.
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