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:

Steri-strips are sterile pieces of medical tape used to close wounds and help the edges grow back together. Steri-strips keep the wound clean and protected while it heals. Steri-strips usually fall off on their own in about 7 to 10 days.

DISCHARGE INSTRUCTIONS:

Return to the emergency department if:

• You have a fever.

• You see red streaks on your skin starting at the wound.

• Your wound has a foul smell or is draining fluid or pus.

• Your wound is red, swollen, and warm to the touch.

• Your wound opens or comes apart.

Contact your healthcare provider if:

• The skin under and around the steri-strips itches or is not comfortable.

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

How to use steri-strips: 

Always wash your hands before you care for your wound. This will help prevent infection. Clean and dry the skin around your wound before you put on new steri-strips.

• Care for the wound as directed. Do not bathe for 24 hours. After 24 hours, wash around the area gently as directed. Pat the area dry with a clean towel, or let it air dry. Do not rub the area with a towel to dry it. Check the wound for signs of infection, such as swelling or pus.

• Only remove the steri-strips if directed. Your healthcare provider may want you to remove the steri-strips after a certain number of days. Do not remove them early, even if they are causing itching or discomfort. If you are directed to remove the steri-strips, pull gently. You might cause the wound to open if you pull hard. Hold the skin down as you slowly and gently remove the strips.

• Apply new steri-strips as directed. 

   ○ Start at the middle of the wound. 

   ○ Gently bring the edges of the wound together and place the middle of the steri-strip on the wound. 

   ○ Do not stretch the steri-strip. 

   ○ Smooth the ends of the steri-strip down onto your skin. 

   ○ Add more steri-strips as needed for the rest of the wound. 

   ○ Leave small gaps between strips so you do not completely cover the wound. Fluid from the wound may build under the strips if you completely cover it. The fluid may make the strips peel. 

   ○ Your healthcare provider may recommend that you add steri-strips down the ends of the pieces you placed across the wound. This will help keep the steri-strips in place as you move.

• Do not scrub or pick at the steri-strips. This can cause your wound to open. Trim the edges of the strips if they start to curl. Then press the ends firmly onto your skin.

Follow up with your healthcare provider as directed: Write down your questions so you remember to ask them during your visits.

© 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.

What is hemorrhoid?

A hemorrhoid is a swollen vein in the area around the anus, the opening through which stool passes. Hemorrhoids are a very common health problem. Many people have both internal and external hemorrhoids.

• Internal hemorrhoids develop inside the anal passageway. They are usually not painful, but they can cause a small amount of bleeding, most often with bowel movements.

• External hemorrhoids develop around the rim of the anus, where they can cause itching and discomfort.

What are the signs of hemorrhoids?

You may see a bit of blood on the toilet paper after having a bowel movement. You might also see traces of blood on your stool or coloring the water inside the toilet bowl. You may feel a bulge or lump in the area around your anus.

What causes them?

Hemorrhoids can develop from chronic constipation, straining to pass stools, and recurrent diarrhea. Women sometimes get hemorrhoids from pregnancy and childbirth. As you get older, you are more likely to develop hemorrhoids.

What is the treatment for hemorrhoids?

Although hemorrhoids are annoying, they are not usually a serious medical problem. Most of the time, you can relieve the symptoms of hemorrhoids with home treatments. However, if you notice rectal bleeding, it is important to see your doctor for an examination. Your doctor will check to see whether the bleeding is coming from hemorrhoids or something more serious, such as rectal cancer.

Recommended home treatments include:

• Increasing the amount of fiber in your diet. A fiber-rich diet softens stools so that they pass more easily, reducing pressure on hemorrhoids

   ○ High-fiber foods include beans, broccoli, carrots, bran, whole grains, and fresh fruits. Ask your doctor for patient handouts on dietary fiber and fiber content of foods. To avoid bloating and gas, add these foods gradually over several days. Drinking enough fluids (six to eight cups a day) helps you digest fiber and also helps soften stools.

   ○ If you don't think you are getting enough fiber in your diet, you can also buy fiber supplements in the drug store (without a prescription). Flavored and artificially sweetened varieties are available. The usual dose is two teaspoons or two packets in liquid once or twice a day.

• Sitz baths. Sitting in a tub filled with warm water for 10 to 15 minutes several times a day can ease discomfort. (Large pharmacies and medical supply stores also sell convenient plastic sitz bath devices that fit into a toilet.) The warm water will keep the area clean, and the warmth will reduce inflammation. Be sure to dry the rectal area thoroughly after each sitz bath. If you work, try taking a sitz bath in the morning, upon your return from work and

before bedtime.

• Applying a cold compress or icepack to the anal area, or try a cool cotton pad soaked in witch hazel.

• Petroleum jelly or aloe vera gel, applied to the anal area, can soothe the skin. Over-the-counter hemorrhoid preparations containing hydrocortisone can reduce swelling, but use them sparingly because they can dry out your

skin.

If hemorrhoids do not respond to these measures, your doctor may recommend medical treatment.

Medical treatments for small to medium, mostly internal hemorrhoids can usually be done in a surgeon’s office. They include:

• Rubber-band ligation - A rubber band is slipped around the base of hemorrhoid to cut off its circulation. Once it has been deprived of its vital blood supply, the banded hemorrhoid withers and falls off. This treatment is the most effective and most common.

• Sclerotherapy - an irritating chemical solution is injected directly into hemorrhoid or the area around it. The solution interferes with blood flow inside the hemorrhoid, causing it to shrink.

• Laser therapy, infrared light therapy, electro-cauterization, or freezing therapy are all used to shrink hemorrhoids.

For patients who have large hemorrhoids, or prominent external hemorrhoids, hemorrhoidectomy (surgically removing the hemorrhoids) is sometimes recommended. This procedure is an outpatient procedure done under anesthesia. It usually has excellent results.

What can I do to prevent another flare-up of hemorrhoids?

• Eat plenty of fiber-rich foods.

• Drink plenty of liquids. To help keep your stool soft, it’s a good idea to drink between six and eight glasses of water daily.

• Exercise regularly. Twenty to thirty minutes of brisk walking daily helps to stimulate easier bowel movements.

• Respond immediately to the urge to have a bowel movement. Do not postpone until the time is more convenient.

Home Treatments for Hemorrhoids

To avoid making hemorrhoids worse:

• After a bowel movement, blot the area gently with white toilet paper moistened with water. You can also use Baby Wipes or other premoistened towels (such as Tucks) for this purpose.

• In the bath or shower, use only soaps without perfumes or dyes. Avoid rubbing the anal area. Gently pat dry with a soft, absorbent, or cloth.

To relieve pain and itching:

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