CHIEF COMPLAINT

Routine INR check and anticoagulation management.

HISTORY OF PRESENT ILLNESS

Maria Chen is a 67-year-old female with a history of atrial fibrillation, hypertension, and mechanical mitral valve replacement (2023) who presents for routine INR monitoring. She reports compliance with her Warfarin 5mg daily regimen. Denies any bleeding, bruising, melena, or hematuria. She notes occasional palpitations lasting seconds, self-resolving. No syncope or presyncope. Diet has been consistent. No new medications or supplements.

REVIEW OF SYSTEMS

Constitutional: No fever, chills, or weight changes.

Cardiovascular: Occasional palpitations as above. No chest pain, dyspnea on exertion, or orthopnea.

GI: No nausea, vomiting, abdominal pain, or change in bowel habits. No blood in stool.

Hematologic: No easy bruising, epistaxis, or gum bleeding.

All other systems reviewed and negative.

PHYSICAL EXAMINATION

Vitals: BP 134/78, HR 72 irregular, RR 16, SpO2 98% on RA, Temp 98.2°F

General: Well-appearing, NAD.

HEENT: No petechiae on palate. No gum bleeding.

Cardiovascular: Irregularly irregular rhythm. Mechanical click noted. No murmurs, rubs, or gallops. No JVD.

Extremities: No edema. No bruising. Peripheral pulses 2+ bilaterally.

Skin: No petechiae or purpura.

ALLERGIES

Penicillin (rash).

ASSESSMENT AND PLAN

1. Atrial fibrillation on anticoagulation

- INR today 2.8 (therapeutic range 2.5-3.5 for mechanical valve)

- Continue Warfarin 5mg daily

- Recheck INR in 4 weeks

2. Hypertension

- Well controlled on current regimen

- Continue Lisinopril 10mg daily, Amlodipine 5mg daily

3. Mechanical mitral valve

- Functioning well. No symptoms of valve dysfunction.

- Annual echo due in 6 months.