CONTACTS 

SUBJECTS
INR 6.4 Blood Test 061214 Very High Danger Risk Hemorraging Contiual

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up
040502 -
040503 -
040504 -
040505 -
040507 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - INR 5.8 Medication Conflict Nortriptyline Acyclovir Prednisone
040902 -
040903 - Laurie called this evening.  She works in a Kaiser Case Management
040904 - Center, and calls patients after normal business hours, possibly in
040905 - Vallejo, not sure.
040907 -  ..
040908 - Laurie reported Kaiser experienced delays processing Millie's blood
040909 - test this morning.  Normally results are posted between 1200 and 1500,
040910 - in time for affected staff to notify patients to adjust medications,
040911 - if required.  This evening, blood test results were still not
040912 - available at 1845, long after the work shift ends at 1700.
040914 -  ..
040915 - Laurie said that INR results have just been posted and show INR 5.8
040916 - for Millie's blood draw at 0830 this morning, ref SDS 4 848J,
040917 - performed by Kaiser in Martinez.
040919 -  ..
040920 - Laurie's report of delayed results aligns with Kaiser's letter just
040921 - received dated 100202 1923, notifying Millie of results for INR from
040922 - the blood test this morning, reported 100202 0830. ref SDS 4 LF6F
040924 -  ..
040925 - INR 5.8 is the second highest in Millie's patient history, and nearly
040926 - doubles the target range 2.0 - 3.0.  Previously, on 061214 Millie's
040927 - INR 6.4 was also well above the target for blood thickness safe to
040928 - prevent pulmonary embolism. ref SDS 1 4O5H  At that time, on 061214,
040929 - Millie's case manager for the Coagulation Control Clinic explained
040930 - that sudden elevated INR was caused by a conflict between Coumadin
040931 - that controls INR blood counts, and a new medication Diflucan
040932 - (fluconazole) prescribed for Millie as an experiment. ref SDS 1 XF77
040934 -  ..
040935 - In the prior situation on 061214, Gloria said that INR increases above
040936 - 6 is a danger zone for risk of continual bleeding (hemorraging), which
040937 - requires immediate treatment to avoid death. ref SDS 1 4O60
040939 -  ..
040940 - Laurie said this evening that since Millie is close to 6.0, Kaiser's
040941 - guidance requires calling and notifying the patient to make
040942 - adjustments.  Laurie also said that she has personally seen and has
040943 - had herself much higher INR test results with no adverse medical
040944 - effects.
040945 -
040946 -            [On 100203 1148 Millie notified medical team that Gloria
040947 -            ordered a 2-day pause in Millie's Coumadin treatments to
040948 -            reduce risks of pulmonary embolism ref SDS 7 J53U
040950 -  ..
040951 - Laurie also cautioned Millie to avoid activity that may cause
040952 - bleeding.  She said Millie should not use excess force brushing her
040953 - teeth, which can cause gums to bleed.  Millie explained she has
040954 - already brushed her teeth this evening, and had no bleeding.  Since
040955 - she is in bed, recuperating from shingles, she will not be doing any
040956 - activity that can cause bleeding.  Millie prepared dinner this
040957 - evening, but did not suffer any cuts.
040959 -  ..
040960 - Laurie asked if Millie noticed any new bruising.
040962 -  ..
040963 - Millie said no.
040965 -  ..
040966 - With the prior incident INR 6.4 on 061214, Gloria recommended eating
040967 - green vegatables and salads, cabbage, broccili, etc., the next few
040968 - days, which will help lower the high INR by thickening the blood.
040969 - ref SDS 1 OH7L
040971 -  ..
040972 - This evening Millie had a green, vegatable salad for dinner, with
040973 - garlic bread and a glass of milk.
040975 -  ..
040976 - Laurie asked if Millie's medications have changed in the past week?
040978 -  ..
040979 - Millie explained that last week Thursday during a meeting on 100128
040980 - 1010, Doctor Johnson in the Oncology Department for Kaiser in Walnut
040981 - Creek, CA, prescribed Nortriptyline taken in the evening to help
040982 - control pain so Millie could sleep, while recovering from Shingles.
040983 - This change in medication was reported in Millie's letter to the
040984 - medical team the same day on 100128 2249, ref SDS 3 FM4W  Doctor
040985 - Johnson also made a report in Millie's medical chart.
040986 -
040987 -            [On 100203 1023 Gloria, Case Manager, Kaiser Coagulation
040988 -            Control Clinic in Martinez reported receiving Millie's
040989 -            letter today on 100128 notifying medical team the the
040990 -            doctor added Nortriptyline to Millie's medications, and did
040991 -            not alert Millie this may affect Coumadin dose and INR
040992 -            blood counts, because Kaiser has gained enough experience
040993 -            using Nortriptyline to establish adjustments to Coumadin,
040994 -            and this can only be determined through trial and error.
040995 -            ref SDS 6 7X4M
040997 -  ..
040998 - Millie has been taking Acyclovir and Prednisone since 100104,
040999 - prescribed initially for 10 days by Doctor Zhang, Adult Care, Kaiser
041000 - Walnut Creek. ref SDS 2 QB5K  Doctor Johnson, Millie's Primary Care
041001 - Physician, subsequently extended this to 2 more 10-day prescriptions.
041002 - Millie's leter to the medical team advised that treatment for shingles
041003 - will end by Friday, 100205.
041005 -  ..
041006 - Millie's INR elevated to 3.7 after taking Acyclovir and Prednisone.
041007 - Gloria in the Coagulation Control Clinic reduced Millie's Coumadin.
041009 -  ..
041010 - Laurie said Millie should not take her Coumadin this evening, and
041011 - that Gloria will call tomorrow with any further instructions.
041013 -  ..
041014 - Millie advised that she has already taken prescribed Coumadin for
041015 - this evening.
041017 -  ..
041018 - Laurie apologized explaining that this medication conflict "slipped
041019 - through the cracks," as discussed previously with Gloria on 061214.
041020 - ref SDS 1 HF4O
041022 -  ..
041023 - Laurie feels that Gloria will call tomorrow and have Millie skip
041024 - Coumadin for 2 days.
041025 -
041026 -            [On 100203 1023 Gloria, Case Manager, Kaiser Coagulation
041027 -            Control Clinic in Martinez reported receiving Millie's
041028 -            letter today on 100128 notifying medical team the the
041029 -            doctor added Nortriptyline to Millie's medications, and did
041030 -            not alert Millie this may affect Coumadin dose and INR
041031 -            blood counts, because Kaiser has gained enough experience
041032 -            using Nortriptyline to establish adjustments to Coumadin,
041033 -            and this can only be determined through trial and error.
041034 -            ref SDS 6 7X4M
041036 -             ..
041037 -            [On 100203 1148 Gloria ordered a 2-day pause in Millie's
041038 -            Coumadin treatments to reduce risks of pulmonary embolism
041039 -            ref SDS 7 J53U
041041 -             ..
041042 -            [On 100203 1148 Millie notified medical team that Gloria
041043 -            ordered a 2-day pause in Millie's Coumadin treatments to
041044 -            reduce risks of pulmonary embolism ref SDS 7 J53U
041046 -             ..
041047 -            [On 100203 1148 Millie notifies medical team that Gloria
041048 -            ordered an interim blood draw to test INR on Friday, and
041049 -            wanst the work performed at Kaiser in Walnut Creek, because
041050 -            that lab can issue same-day results, needed to adjust
041051 -            Coumadin on Friday, 100205, and the lab in Kaiser,
041052 -            Martinez, where Millie usually gets blood draws on
041053 -            Tuesdays, does not provide same-day results. ref SDS 7 J53X
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