Warfarin (WAR-far-in) (By mouth)

Prevents and treats blood clots. May lower the risk of serious complications after a heart attack. This medicine is a blood thinner.

Brand Name(s): Coumadin, Jantoven

There may be other brand names for this medicine.

When This Medicine Should Not Be Used:

This medicine is not right for everyone. Do not use it if you had an allergic reaction to warfarin, if you are pregnant, or if you have health problems that could cause bleeding.

How to Use This Medicine:

Tablet

• Take your medicine as directed. Your dose may need to be changed several times to find what works best for you.

• This medicine should come with a Medication Guide. Ask your pharmacist for a copy if you do not have one.

• Missed dose: Take a dose as soon as you remember. If it is almost time for your next dose, wait until then and take a regular dose. Do not take extra medicine to make up for a missed dose.

• Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light.

Drugs and Foods to Avoid:

Ask your doctor or pharmacist before using any other medicine, including over-the-counter medicines, vitamins, and herbal products.

• Many medicines and foods can affect how warfarin works and may affect the PT/INR test results. Tell your doctor before you start or stop any medicine, especially the following:

   ○ Co-enzyme Q10, echinacea, garlic, ginkgo, ginseng, goldenseal, or St John's wort

   ○ Another blood thinner, including apixaban, argatroban, bivalirudin, cilostazol, clopidogrel, dabigatran, desirudin, dipyridamole, heparin, lepirudin, prasugrel, rivaroxaban, ticlopidine

   ○ Medicine to treat depression or anxiety, including citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, milnacipran, paroxetine, sertraline, venlafaxine, vilazodone

   ○ Medicine to treat an infection

   ○ NSAID pain or arthritis medicine, including aspirin, celecoxib, diclofenac, diflunisal, fenoprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, mefenamic acid, naproxen, oxaprozin, piroxicam, sulindac. Check labels for over-the-counter medicines to find out if they contain an NSAID.

   ○ Steroid medicine, including dexamethasone, hydrocortisone, methylprednisolone, prednisolone, prednisone

• Warfarin works best if you eat about the same amount of vitamin K every day. Foods high in vitamin K include asparagus, broccoli, brussels sprouts, cabbage, green leafy vegetables, plums, rhubarb, and canola oil. Talk to your doctor before you make changes to your normal diet.

• Do not eat grapefruit or drink grapefruit juice while you are using this medicine.

Warnings While Using This Medicine:

• It is not safe to take this medicine during pregnancy. It could harm an unborn baby. Tell your doctor right away if you become pregnant. Use an effective form of birth control to keep from getting pregnant during treatment and for at least one month after your last dose.

• Tell your doctor if you are breastfeeding, or if you have kidney disease, liver disease, heart disease, diabetes, heart failure, high blood pressure, an infection, a stomach ulcer, or protein C deficiency. Also tell your doctor if you had recent surgery or an injury, or a history of stroke, anemia, severe bleeding or bruising, or problems caused by heparin use.

• This medicine may cause the following problems:

   ○ Bleeding, which may be life-threatening

   ○ Gangrene (skin or tissue damage)

   ○ Calciphylaxis or calcium uremic arteriolopathy

   ○ Kidney problems, including acute kidney injury

   ○ Purple toes syndrome

• You must have a PT/INR blood test while you use this medicine to check how well your blood is clotting. Your doctor will use the test results to make sure the medicine is working properly. Keep all appointments for the PT/INR blood tests.

• You may bleed or bruise more easily with warfarin. To prevent injury or cuts, do not play rough sports, be careful with sharp objects, and brush and floss your teeth gently. Blow your nose gently, and do not pick your nose.

• Carry an ID card or wear a medical alert bracelet to let emergency caregivers know that you use warfarin.

•Tell any doctor or dentist who treats you that you are using this medicine. You may need to stop using this medicine several days before you have surgery or medical tests.

• Keep all medicine out of the reach of children. Never share your medicine with anyone.

Possible Side Effects While Using This Medicine:

Call your doctor right away if you notice any of these side effects:

• Allergic reaction: Itching or hives, swelling in your face or hands, swelling or tingling in your mouth or throat, chest tightness, trouble breathing

• Bleeding from your gums or nose, coughing up blood, heavy monthly periods

• Bleeding that does not stop, bruising, or weakness

• Dizziness, fainting, lightheadedness

• Pain, brown or black skin, or skin that is cool to the touch

• Purple toes or feet, or new pain in your leg, foot, or toes

• Purplish red, net-like, blotchy spots on the skin

• Red or dark brown urine, or red or black, tarry stools

• Vomiting blood or material that looks like coffee grounds

If you notice other side effects that you think are caused by this medicine, tell your doctor.

© 2017 Truven Health Analytics LLC

WHAT YOU NEED TO KNOW:

What is a metered-dose inhaler and a spacer?

A metered-dose inhaler is a handheld device that gives you a dose of medicine as a mist. You breathe the medicine deep into your lungs to open your airways. A spacer is a tube that attaches to the mouthpiece of your metered-dose inhaler. The spacer helps make your inhaler easier to use. It also helps get the medicine into your lungs better. Your medicine stays in the spacer for a short amount of time. This allows you to breathe one deep breath. You can also breathe in and out at a normal rate up to 5 times. Your healthcare provider will teach you how to use your inhaler and spacer.

How do I use my inhaler with a spacer?

Practice using your inhaler and spacer. Your medicine will work best if you use them correctly. The steps below will help you use your inhaler and spacer correctly:

• Prepare your inhaler and spacer:

   ○ Remove the caps from your inhaler and spacer. Check to make sure there is nothing in the mouthpiece that could block the medicine from coming out.

   ○ Put the spacer onto the inhaler.

   ○ Shake the inhaler to mix the medicine.

   ○ Hold the inhaler upright, with the mouthpiece of the spacer pointing towards your mouth.

• Get ready to breathe in the medicine:

   ○ Keep your mouth away from the mouthpiece, and breathe out fully to clear your lungs.

   ○ Place the mouthpiece between your lips. Close your lips around the mouthpiece to form a seal and prevent a medicine leak. If you cannot put your mouth around the mouthpiece, your healthcare provider will give you a spacer with a mask attached. Hold the mask firmly to your face.

   ○ Press down the canister and breathe in slowly. This helps the medicine get into your lungs. Make sure to breathe in within 2 seconds of pressing down the canister.

   ○ Hold your breath for at least 5 seconds. This will help the medicine reach all parts of your lungs, including the smaller parts called the alveoli.

   ○ Breathe out slowly through pursed lips. This helps to keep your airway open and allows the medicine to be absorbed into more areas.

   ○ Repeat puffs of medicine as directed by your healthcare provider. Wait about 2 minutes between puffs. If you need to use a bronchodilator and a steroid inhaler, use the bronchodilator first. Wait 5 minutes then use the steroid inhaler.

   ○ Gargle with warm water to remove any leftover medicine from your mouth and throat.

How do I care for my inhaler and spacer?

Pull your inhaler and mouthpiece apart. Put the caps back on both. Clean your spacer and inhaler at least weekly. Remove the canister from your inhaler before cleaning. Wash your spacer and inhaler with warm soapy water. Rinse and allow to air dry. Make sure both are completely dry before using.

When should I seek immediate care?

• Your lips or nails turn blue or gray.

• The skin between your ribs or around your neck pulls in with every breath.

• You feel short of breath, even after you use your inhaler.

When should I contact my healthcare provider?

• You have to take more puffs from the inhaler than directed, in order to get relief.

• You run out of medicine before your next refill is due.

• You feel like your medicine is not making your symptoms better.

• You have questions or concerns about your condition or care.

CARE AGREEMENT:

You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment.

© 2017 Truven Health Analytics LLC All illustrations and images included in CareNotes® are the

copyrighted property of A.D.A.M., Inc. or Truven Health Analytics.

Shoulder pain is a common problem, usually caused by strains and sprains of the soft tissues surrounding the shoulder joint. In most cases, the pain gets better with simple treatments you can do at home.

What is shoulder pain?

Three bones (the upper arm bone, the shoulder blade, and the collar bone) join to form your shoulder. These bones fit into sockets with cartilage, muscles, and tendons protecting the joints (see image).

This structure gives your shoulder a wide range of motion. Pain develops when any of the soft tissues or bony structures are over-extended or injured.

What causes shoulder pain?

The cause of shoulder pain depends on how the pain began and where it is felt. Acute pain after an injury is usually caused by muscle or tendon strains or tears (most commonly a "rotator cuff injury"). Pain in the shoulder not due to an acute event often begins gradually and may come and go. This type of pain can have many causes, including:

• Tendon, ligament or muscle strains

• Chronic tears (rotator cuff)

• Inflamed bursae (bursitis)

• Arthritic changes damaging the cartilage or causing impingement and inflammation

Fractures of the bones of the shoulder (arm, collar, shoulder blade) are uncommon because it requires significant trauma to break a shoulder bone. However, older people and people with osteoporosis can develop fractures with less trauma.

How is shoulder pain treated?

Most shoulder pain can be controlled with simple home treatments.

• Rest and activity changes:

   ○ Avoid any movement that causes pain.

   ○ Avoid moving your arm higher than chest level.

   ○ Do not lift, carry, or pull heavy objects.

   ○ Sleep on the non-painful side with a flat pillow under your armpit to protect the shoulder that hurts.

   ○ If recommended, use a sling to immobilize your shoulder for a few days.

What is osteoarthritis?

Osteoarthritis is the most common form of arthritis. It affects the joints and the tissue (cartilage) around the joints that help absorb shock when you move. Osteoarthritis may cause pain, but redness and swelling, symptoms of rheumatoid arthritis and other autoimmune diseases, are not signs of osteoarthritis.

What happens to the joints when you have osteoarthritis?

The cartilage protecting the joints can break down and wear away. Over time, this allows the bones at the joint to rub together. The rubbing causes pain, swelling, and stiffness. After a while, the joint may lose its flexibility.

What causes osteoarthritis?

Osteoarthritis develops slowly, usually through normal wear and tear on the joints. Some risk factors are:

• Being overweight

• Getting older

• Family history

• Stresses on the joints from some kinds of work and some sports

• Old injuries

What are the symptoms of osteoarthritis?

People with osteoarthritis usually have at least some joint pain and stiffness. The pain occurs most often in the hands, knees, hips, and spine. Other common symptoms are:

• Stiffness after getting out of bed or sitting for a long time

• Swelling or tenderness in one or more joint(s)

• A crunching feeling or sound in the affected joint(s)

How does my doctor know I have osteoarthritis?

There is no special test that can tell you have osteoarthritis. Your doctor may look at:

• Your medical history

• The results of your physical exam

Neck pain is a common problem that may be triggered by poor posture, a mild neck injury, or just age-related wear and tear. In most cases, the pain gets better with simple treatments you can do at home.

What is neck pain?

Everyone gets pain in the neck from time to time. Neck pain can occur anywhere in your neck, from the bottom of your head to the top of your shoulders. It can spread to your upper back or arms. Your neck may feel sore or stiff. The pain might limit how much you can move your head and neck.

Neck pain is rarely the sign of a serious illness. Most people feel better within a few days to a couple of weeks.

What causes neck pain?

Some common causes of neck pain are:

• Muscle tightness due to poor posture or stress

• Inflammation and muscle spasms caused by neck strain or injury

• Wear and tear related to aging

• Accidents causing whiplash, a quick forward and backward movement that strains the neck

As you get older, you are more likely to develop neck pain. Neck pain may be the result of age-related changes in the vertebrae, discs, muscles, and ligaments of the neck. Even simple daily activities, such as working at a computer or reading in bed, can strain your neck.

How is neck pain diagnosed?

WHAT YOU NEED TO KNOW:

What is a laceration? A laceration is an injury to the skin and the soft tissueunderneath it. Lacerations happen when you are cut or hit by something.They can happen anywhere on the body.

What are the signs and symptoms of a laceration? Lacerations can be many shapes and sizes. The open skin may look like a cut, tear, or gash. The wound may hurt, bleed, bruise, or swell. Lacerations in certain areas of the body, such as the scalp, may bleed a lot. Your wound may have edges that are close together or wide apart. You may have numbness around the wound. You may have decreased movement in an area below the wound.

What is acute low back pain?

Low back pain is a very common medical problem. It involves pain at the base of the lower back, and it can affect the buttocks and upper thighs, too. ”Acute" low back pain means new pain that has lasted less than one month.

What causes low back pain?

Your chance of having back pain is increased by things like not getting enough exercise, being overweight, having a physically demanding job, cigarette smoking, and simply getting older.

Most back pain occurs at the bottom of the spine because this area holds most of your weight and keeps you standing up straight. The major parts of your back include bones, muscles, nerves, discs (which sit between the bones of your spine, keeping them separated and absorbing shock) and ligaments (which hold the bones together, provide support, and help with movement). Some of the nerves branch out from between the bones. Some go to your back and others go down your legs. This is why back problems can cause leg pain, too.

Most low back pain is "non-specific”， which means that the exact cause can’t be easily identified. While it’s often due to the muscles, ligaments and/or bones, there isn’t a specific problem. Sometimes, the cause can be identified, especially when the back pain spreads into one or both legs, most commonly due to (1) sciatica due to a disc problem, which is more common in people younger than 50, or (2) spinal stenosis, a type of arthritis more common in people over 60.

1. Sciatica (say it：”sy”at-ih-cah") is a specific type of low back pain that most commonly spreads into one leg. The pain is usually sharp or burning, and it’s felt down the back or side of the leg, typically below the knee, to the foot or ankle. Most people with sciatica also have pain in their back. The most common cause of sciatica is a bulging or herniated （”burst”） disc that pinches a nerve along the spinal column. However, many people with no symptoms at all also have a bulging disc, so a disc bulge doesn't necessarily cause symptoms.

2. Spinal stenosis is a specific type of low back pain usually caused by arthritic changes in the back in older patients. Bony deposits called “spurs “grow along the bones of the back. Sometimes they close in on the spinal canal, the space where nerve roots branch off from the spinal cord. This makes the space more narrow, a condition called spinal stenosis. This can also put pressure on the nerves, causing pain. The pain from spinal stenosis can occur in the lower back or buttocks alone, or it can go into the groin or one or both legs. The legs may feel numb, tingling, or heavy. Walking worsens the pain. It can make you feel clumsy and afraid of falling. Unlike most other types of back pain, sitting down usually relieves the pain and lying down can make the pain worse.

How will my clinician figure out what’s causing my pain?

Your clinician will listen to you describe your symptoms, do a physical exam, and ask you questions. These questions may include:

• Have you had back problems before?

• What makes the pain better or worse?

• Exactly where do you feel the pain?

• Do you have numbness or weakness that makes it hard to move around?

• What you were doing around the time your pain started? (Don’t worry if you can’t remember what you were doing. Most back pain isn’t caused by a specific event or injury.)

In most cases, this will give your clinician enough information to identify common issues and rule out rare but serious issues. It will also help your clinician to decide the first steps of treating your pain.

Will x-rays or other tests be helpful?

Have you ever felt discomfort during exercise like shortness of breath, chest pain, numb and sharp pain on your arm or lower jaw?

Actively participating in a variety of sports is becoming a healthy lifestyle. However, along with the increase of the exercise intensity, the risks of sports-related cardiovascular problem also increases. There are more and more reports of sudden cardiac death (SCD). Our advice for amateurs and professional athletes is to do a cardiopulmonary exercise testing to rule out the risk of latent cardiovascular diseases, to prevent the risk of sudden death, and to reach a better exercise effect.

What is the sudden cardiac death (SCD)?

Most cases of sudden cardiac death (SCD) are caused by malignant arrhythmia, which is often ventricular Tachycardia (VT) or ventricular Fibrillation (VF). For individuals with heart diseases like hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy, competitive sports can increase VT/VF risks.

Even though SCD rarely happens, once it does it can lead to disastrous consequence. Among young SCD victims, although the causes of death in most cases are unclear, many of them have undiagnosed cardiovascular diseases. Therefore, it is necessary to have a screening as soon as possible and take preventive measures suggested by doctors to lower the SCD risk.

What diseases are the origins of SCD risk?

For those with basic cardiovascular disease, competitive and recreational sports can increase the SCD risk. The risk is related to the severity of basic disease and exercise intensity. Among group under the age of 35, SCD is mostly caused by basic structural heart disease; among those above 35, the SCD is more likely to be caused by coronary disease. In daily life, it is advisable to pay particular attention to the screening of relevant diseases.

What symptoms during exercise should be taken seriously?

Pay attention to the exercise-related chest pain, especially lasting one. If you feel shortness of breath, numbness and sharp pain on the left arm or lower jaw that you have never experienced, you should be careful. In addition, unusual weariness should not be ignored. If you find that you cannot run as far as before, please see a doctor as soon as possible.

How to do the screening?

Like the screening of other diseases, the screening of heart disease before exercise aims to identify SCD risk and mainly improve the prognosis through exercise restriction/adjustment or other specific therapies for basic disease.

The screening methods depend on age and expected intensity of exercise, competitive or recreational. Normally it includes initial risk assessment, standard 12- lead ECG, and exercise stress test.

Initial risk assessment: Based on consultation, analysis on available material, patient’s medical background, doctor will develop further examination plan.

Examination plan: Standard 12-lead ECG and exercise stress test

Standard 12-lead ECG: One of the most extensive examinations in clinical applications that can show the electrical activities of the heart.

Exercise stress test: It includes treadmill test or CPET (Cardiopulmonary Exercise Test). It increases cardiopulmonary load through exercise (treadmill or bicycle) to observe the changes in the ECG during exercise and the functional change of the cardiopulmonary system.

Safety assessment: The doctor assesses the safety of exercise according to the result of your examinations, and proposes a further examination/treatment plan.

Please follow doctor’s guidance to choose the package you need