Besides us is one mitral valve disease, kind of status post mitral valve replacement with a st.

Jude's
prosthetic valve, coronary artery, bypass x 1 then hospital to history of two previous cerebrovascular
accident, secondary to a balance disorder from Aunt, fanatic with anticoagulation three atrial fibrillation.
Come on Providence with INR 3.1 and What possible, t.i. A on kind of yesterday, common with right arm,
weakness and numbness?

Beginning of you, put this patient returns to Cardiology clinic in this. Not feel well today, period. He
thinks that he had a TI a yesterday in which he had sudden, right arm weakness period. His EKG Today,
Show's actual circulation with the control Centre can response, and T wave inversions consistent with
ischemia period. This sounds like the same appearing EKG that has previously been done in January
comma. However,

Found two, that had the EKG for comparison. Period patient is on soda loyal and it would appear
reasonable to stop this medication. Period patient occasionally has engine about twice a month. We
leave by nitroglycerin period patient has followed by doctor. The patient had a cardiac Echo done. And
in this study left, ventricular function was seem to be normal prosthetic mitral valve of the building. This
variety was working. Well, and there was a question of an atrial septal defect. However, their, this was
not and well-documented, a pair of appropriately and the mitral valve appear to function well, and
patient was in atrial fibrillation at that time, period.

Physical examination today, BP is 149 of the 69th left 167 over 72, right of 89. In the regular weigh. 280
pounds chest is clear, but examination, reveals good. Prosthetic thinks of the mitral valve prosthesis
period. There is a low-pitched rumble in diastole, which is appropriate period. There is no mitral
regurgitation clinically period. There was no edema period comments and recommendations. Asians as
patient those with mitral valve replacement and atrial fibrillation. INR should be 3.5 to 4 .5, especially in
the setting of previous embolic episodes period EKG. Suggested suggesting ischemia is of concern and
patients should probably have a salary in imaging study period. The package, my plan will be to stop the
soda. Loyal patient has been clinically in atrial fibrillation.

Come up, we place them on metoprolol XL, 25 mg today, for hypertensive control, which may be
increased period. And going to give the patient a copy of his EKG. And suggested that very strongly that
he see his primary has local private, cardiologist after full continue it for consideration of Kali Imaging
comma, possibly transesophageal Echo to assess mitral valve comma possible. PC caught a fever. First
period, I will plan A cardiology follow-up in our clinic and the next available spot. Probably six to nine
months to review the patient period. I am not going to order. I repeat Echo period and