PRIMARY CARE PHYSICIAN:
CC:Follow-up anticoagulation.
HISTORY:
PMHx: DM, HTN, hyperlipidemia
Primary Warfarin Indication:
Secondary Indication:
Indication Description:
Atrial Fibrillation
Not Applicable
No additional comments.
Signs/Symptoms Bleeding (See "Heme History" below for details):
Nose Bleeds:
No
Gum Bleeds:
No
Change in Urine Color:
No
Change in Stool Color:
No
Bright Red Blood per Rectum:
Yes
Abnormal Bruising:
No
Signs/Symptoms of Potential Embolic Events:
No
Heme_History: patient reports occasional rectal bleeding with constipation which he contributes to hemorrhoids,
unchanged.
Current EtOH Use:
Current Smoker:
No
No
Changes In (See "Additional History" below for details):
Diet:
Yes
Medications:
No
Activities / Lifestyle:
No
Health Status:
No
Additional History: patient increased intake of vit K foods from once weekly to five times weekly. He continues to
consume 2 glasses of wine per week. He notes fasting glucose readings at home ranging from 152 to 180 over the past 2
weeks. He denies hypoglycemic episodes. Denies polyuria, polydipsia, polyphagia. He denies missed doses of any
meds.
Additional Assessment:
INR subtherapeutic likely due to increase in vit K foods; therapeutic at last visit on same dose.
DM: uncontrolled; meter download: 14 day avg: 172
Medications were reviewed and updated:
Yes
Informed Patient or Caretaker:
Yes
Patient or Caretaker Verbalize Understanding: Yes
Warfarin Handout(s) Provided: No
ASSESSMENT/PLAN:
Well appearing in no acute distress.
Date INR:
9/4/2008
Site Test Performed: UNC
Goal INR: 2 - 3
INR Results:
1.7
Current Dose: 5mg MWF, 2.5mg TRSS
Plan for Warfarin Dose:
Increase current dose to 2.5mg MWF, 5mg TRSS.
Repeat INR Date:
9/18/2008
2. DM: increase metformin 500mg po bid to 1000mg po bid. Continue to monitor glucose readings, bring meter to follow
up visit for further assessment and medication adjustment.
Total time spent face-to-face with this patient at this visit was 35 minutes.