1. Mitral valve disease, status post mitral valve replacement with a St. Jude prosthetic
valve XXXX and coronary artery bypass X 1 done at
2. History of 2 previous cerebrovascular accidents secondary to embolic disorder from inadequate anticoagulation.
3. Atrial fibrillation, on Coumadin with INR 3.1 on XXXX.
4. Possible transient ischemic attack, yesterday, with right arm weakness and numbness.
SUBJECTIVE: This patient returns to Cardiology Clinic and does not feel well today. He thinks that he had a transient ischemic attack yesterday in which he had sudden right arm weakness. His EKG today shows atrial fibrillation with a controlled ventricular response and T wave inversions consistent with ischemia. This sounds like the same appearing EKG that had previously been done in January; however, I did not have the EKG for comparison. The patient is on sotalol and it would appear reasonable to stop this medication. The patient occasionally has angina, about twice a month, relieved by nitroglycerin. The patient is followed by Dr. XXXX. The patient had a cardiac echocardiogram done XXXX, and in this study, left ventricular function was seen to be normal. Prosthetic mitral valve of a tilting disc variety was working well, and there was a question of atrial septal defect; however, this was not at all documented appropriately and the mitral valve appeared to function well, and the patient was in atrial fibrillation at that time.
Vital signs: Blood pressure: 149/69 left, and 167/72 right. Pulse: 89 and irregular. Weight: 180 pounds.
Lungs: Chest is clear.
Heart: Cardiac examination reveals good prosthetic clicks of the mitral valve prosthesis. There was a low pitched rumble in diastole, which is appropriate. There was no mitral regurgitation clinically. There was no edema.
COMMENTS/RECOMMENDATIONS: As the patient knows, with mitral valve replacement and atrial fibrillation, INR should be 3.5 to 4.5, especially in the setting of previous embolic episodes. EKG suggesting ischemia is of concern, and the patient should probably have a thallium imaging study.
PLAN: My plan will be to stop sotalol since the patient has been chronically in atrial fibrillation, place him on metoprolol XL 25 mg per day for hypertensive control which may be increased. I am going to give the patient a copy of his EKG and I suggested to him very strongly that he see his local private cardiologist Dr. XXXX for consideration of thallium imaging, possibly transesophageal echocardiogram to assess mitral valve, and possible DC cardioversion. I will plan a cardiology followup in our clinic in my next available slot, probably 6 to 9 months, to re-review the patient. I am not going to order a repeat echocardiogram.
Cardiology Dictation Key