A 50-Year-Old Man Comes to the Office for a Routine

A 50-year-old man comes to the office for a routine physical.  He has had no recent concerns and his review of systems is unremarkable.  Five years ago, the patient underwent mechanical aortic valve replacement due to endocarditis.  Since then, he has been taking warfarin for anticoagulation and has been compliant with the regimen.  The patient is a lifelong nonsmoker.  All his vaccinations are up to date.  He is afebrile, blood pressure is 122/65 mm Hg, and pulse is 73/min and regular.  On auscultation, a 2/6 diastolic murmur is heard at the left sternal border and is best appreciated with a breath-hold at expiration.  The lungs are clear.  Abdominal and extremity examinations are unremarkable.  His last INR check 5 days ago was 2.9.  Which of the following is the best next step in management of this patient?

A) Complete blood count with blood smear
B) Echocardiography
C) Exercise stress testing
D) Hypercoagulability studies
E) Routine clinical follow-up

Correct Answer:

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