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Assignment Instructions:
W is a 42 year old male with a new onset of DVT as confirmed by venous doppler. He has a history of a DVT 5 years ago and currently takes Aspirin 81 mg daily.
What evidence based treatment plan should be initiated for this patient? Be specific including what medications, labwork, expected outcomes, and patient teaching.W is a 42 year old male with a new onset of DVT as confirmed by venous doppler. He has a history of a DVT 5 years ago and currently takes Aspirin 81 mg daily.
PLEASE WRITE THIS IN A SOAP NOTE FORMAT,
PROVIDE SPECFIC MEDICATION BY NAME AND TREATMENT PLAN
THE SPECFIC DOSE AMOUNT OF MEDICATION AND DURATION
FOLLOW UP CARE
How To Work On This Assignment(Example Draft/Essay)
Subjective: W is a 42-year-old male who presents with a new onset of deep vein thrombosis (DVT). The diagnosis was confirmed by venous doppler. He reports a history of DVT 5 years ago and is currently taking Aspirin 81 mg daily. The patient denies any chest pain, shortness of breath, or swelling in his legs.
Objective: On physical examination, the patient had mild swelling in his left calf, with no erythema or tenderness. Vital signs were within normal limits, with a blood pressure of 128/76, heart rate of 80 beats per minute, respiratory rate of 16 breaths per minute, and temperature of 98.6 degrees Fahrenheit.
Assessment: The patient has a new onset of DVT, with a history of DVT and current aspirin therapy.
Plan: To manage the patient’s DVT, we recommend the following evidence-based treatment plan:
Initiate anticoagulation therapy, considering the patient’s history of DVT and current aspirin therapy.
Start therapeutic dose of enoxaparin (Lovenox) at 1 mg/kg subcutaneously every 12 hours for 5-7 days, or until the INR is therapeutic.
After 5-7 days, transition to warfarin (Coumadin), targeting an INR between 2.0 and 3.0, for a total treatment duration of 3-6 months.
Monitor complete blood count (CBC), prothrombin time (PT)/INR, and activated partial thromboplastin time (aPTT) initially and throughout the treatment.
Follow up with a hematologist for long-term management of thrombophilia.
Educate the patient on the importance of compliance with medication regimen, signs and symptoms of bleeding or recurrent DVT, and the need for regular laboratory monitoring.
Follow-up: To ensure successful management of the patient’s DVT, we recommend the following follow-up care:
Schedule a follow-up appointment in one week to monitor INR levels and adjust warfarin dosing as necessary.
Provide the patient with a prescription for enoxaparin (Lovenox) and warfarin (Coumadin).
Instruct the patient to seek immediate medical attention if he experiences any signs or symptoms of bleeding or recurrent DVT.
Expected outcomes: With the initiation of anticoagulation therapy, the patient’s DVT is expected to resolve without further complications. Close monitoring of INR levels and laboratory values will help ensure adequate therapeutic levels and prevent bleeding complications. The patient should continue to take medication as prescribed and maintain regular follow-up appointments to monitor his condition.
SOAP Note:
Subjective:
Patient W, a 42-year-old male presents with a new onset of DVT, confirmed by venous doppler. He has a history of DVT 5 years ago and currently takes Aspirin 81 mg daily. The patient denies any chest pain, shortness of breath, or swelling in his legs.
Objective:
On physical examination, the patient had mild swelling in his left calf, with no erythema or tenderness. Vital signs were within normal limits, with a blood pressure of 128/76, heart rate of 80 beats per minute, respiratory rate of 16 breaths per minute, and temperature of 98.6 degrees Fahrenheit.
Assessment:
New onset of DVT, history of DVT, current aspirin therapy.
Plan:
Initiate anticoagulation therapy, considering the patient’s history of DVT and current aspirin therapy.
Start therapeutic dose of enoxaparin (Lovenox) at 1 mg/kg subcutaneously every 12 hours for 5-7 days, or until the INR is therapeutic.
After 5-7 days, transition to warfarin (Coumadin), targeting an INR between 2.0 and 3.0, for a total treatment duration of 3-6 months.
Monitor CBC, PT/INR, and aPTT initially and throughout the treatment.
Follow up with a hematologist for long-term management of thrombophilia.
Educate the patient on the importance of compliance with medication regimen, signs and symptoms of bleeding or recurrent DVT, and the need for regular laboratory monitoring.
Follow-up:
Schedule a follow-up appointment in one week to monitor INR levels and adjust warfarin dosing as necessary.
Provide the patient with a prescription for enoxaparin (Lovenox) and warfarin (Coumadin).
Instruct the patient to seek immediate medical attention if he experiences any signs or symptoms of bleeding or recurrent DVT.
Expected outcomes:
Anticoagulation therapy is expected to resolve the patient’s DVT without complications. Close monitoring of INR levels and laboratory values will help ensure adequate therapeutic levels and prevent bleeding complications. The patient should continue to take medication as prescribed and maintain regular follow-up appointments to monitor his condition.
