PRIMARY CARE PHYSICIAN:
PRIMARY CARE PHYSICIAN:CC:Follow-up anticoagulation.HISTORY:PMHx:DM, HTN, hyperlipidemiaPrimary Warfarin Indication: Atrial FibrillationSecondary Indication: Not ApplicableIndication Description: No additional comments.Signs/Symptoms Bleeding (See "Heme History" below for details):Nose Bleeds:NoGum Bleeds:NoChange in Urine Color:NoChange in Stool Color:NoBright Red Blood per Rectum:YesAbnormal Bruising:NoSigns/Symptoms of Potential Embolic Events:NoHeme_History: patient reports occasional rectal bleeding with constipation which he contributes to hemorrhoids, unchanged.Current EtOH Use:NoCurrent Smoker:NoChanges In (See "Additional History" below for details):Diet:YesMedications:NoActivities / Lifestyle:NoHealth Status:NoAdditional 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: 172Medications were reviewed and updated:YesInformed Patient or Caretaker:YesPatient or Caretaker Verbalize Understanding:YesWarfarin Handout(s) Provided:NoASSESSMENT/PLAN:Well appearing in no acute distress.Date INR:9/4/2008Site Test Performed:UNC Goal INR:2 - 3INR Results: 1.7Current Dose: 5mg MWF, 2.5mg TRSSPlan for Warfarin Dose: Increase current dose to 2.5mg MWF, 5mg TRSS. Repeat INR Date: 9/18/20082. 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. ................
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