Pharmacologic Management of Warfarin Toxicity in a Patient with a Mechanical Heart Valve and Polypharmacy

Chief Complaint (CC): HG is a 57-year-old white male who presents to your clinic with complaints of frequent nosebleeds (three in the last week), easy bruising, palpitations, weakness, swelling in the feet and lower legs, abdominal discomfort, and a lack of appetite. He has also been experiencing some chest pains over the past month. It’s most likely to occur after he has exerted himself and goes away when he sits and rests for a few minutes. In addition, HG complains that he has a cold. History of Present Illness (HPI): HG has a prosthetic heart valve for which he has been anticoagulated with warfarin (Coumadin®) for the past 5 years. He has a history of congestive heart failure, osteoarthritis of the knee, and nocturnal heartburn. He has started taking cimetidine (Tagamet®) about a month ago which he purchased over the counter (cimetidine has been known to inhibit the metabolism of warfarin). He is also being evaluated for HTN. His previous two blood pressure readings have been 170/90 and 165/92. Social History (SH): Tobacco use: smokes ½ pack per day Alcohol: rarely consumes any alcohol Allergies: NKA Medication History: Warfarin (Coumadin®) 7mg daily Carvedilol (Coreg®) 6.25 mg two times daily Lisinopril (Zestril®) 10 mg daily Furosemide (Lasix®) 20 mg daily as needed for edema Cimetidine (Tagamet®) 150mg two times daily Pseudoephedrine (Sudafed® 12 HR) 120mg two times daily Magnesium hydroxide (Phillips’® Milk of Magnesia) 15ml (400 mg/5 mL) three times daily as needed for heartburn Ibuprofen (Motrin®) 200mg every 6 hours as needed Physical Examination: GEN: Well developed, well-nourished man VS: HR 100, BP 175/96, RR 14, Wt 96kg, Ht 5’11” HEENT: WNL COR: slight ventricular enlargement CHEST: WNL ABD: (+) bowel sounds EXT: bruising on arms and knees; 2+ pitting edema NEURO: A&O x3 Laboratory Tests: Na 143 K 4.0 Cl 98 HCO3 22 BUN 12 SCr 0.9 Gluc 100 WBC 5.0 Hct 45 Hgb 15 Plt 300 Total Cholesterol 240 LDL 170 HDL 34 Trig 180 INR 5.0 

Writing a Case Study: Part Two—”SO” of the SOAP Note Once you have identified a problem, the next step is to analyze your problem. First, identify subjective (S) and objective (O) information that substantiates your problem. S/O may include laboratory values, tests, information obtained from the physical examination, patient history, current medications that are pertinent to the problem, etc. Only include the information that pertains to the problem that you are addressing. 

Writing a Case Study: Part Three—”AP” of the SOAP Note Take your problem, assess the current therapy/problem, and develop a plan. Your assessment may be that all is well with therapy and have patient continue current therapy – or you may need to initiate therapy, order tests, labs, and/or procedures. You may discontinue current therapy and add new therapy. Most often when you consider all the therapeutic classes and all the potential medications within a class of medications, the possibilities for treatment are numerous, so don’t be discouraged if you don’t come up with the same plan as your classmates. For this assignment and all others in this course, you will assume the role of prescriber. Be sure that for your problem, you specify what goals you are trying to achieve. If you prescribe medications, you need to be specific. For example, you cannot say to start an antihistamine for the patient’s allergies. You will need to state the specific medication, dose, dosing interval, duration, and any other information necessary to write a prescription and properly care for the patient. You will also need to list monitoring parameters. Monitoring can include any necessary laboratory tests but can also include something as simple as asking if the patient’s rhinorrhea is resolved. You may also include future plan if necessary and drugs to be avoided if appropriate. Lastly don’t forget to include important educational information regarding medications that you are prescribing. For example, if you are prescribing diphenhydramine for the patient’s allergies, it would be important to warn the patient about CNS depressive effects. We would not want the patient to fall asleep while driving and cause an accident. Please provide education in regard to only the most common potential side effects.