Doctor's Address,Dear Doctor:,This letter is an introduction to my patient, A, who you will be seeing in the near future.  He is a pleasant gentleman with a history of Wilson's disease.  It has been treated with penicillamine.  He was diagnosed with this at age 14.  He was on his way to South Carolina for a trip when he developed shortness of breath, palpitations, and chest discomfort.  He went to the closest hospital that they were near in Randolph, North Carolina and he was found to be in atrial fibrillation with rapid rate.  He was admitted there and observed.  He converted to normal sinus rhythm spontaneously and so he required no further interventions.  He was started on Lopressor, which he has tolerated well.  An echocardiogram was performed, which revealed mild-to-moderate left atrial enlargement.  Normal ejection fraction.  No other significant valvular abnormality.  He reported to physicians there that he had cirrhosis related to his Wilson's disease.  Therefore hepatologist was consulted.  There was a recommendation to avoid Coumadin secondary to his questionable significant liver disease, therefore he was placed on aspirin 325 mg once a day.,In discussion with Mr. A and review of his chart that I have available, it is unclear as to the status of his liver disease, however, he has never had a liver biopsy, so his diagnosis of cirrhosis that they were concerned about in North Carolina is in doubt.  His LFTs have remained normal and his copper level has been undetectable on his current dose of penicillamine.,I would appreciate your input into the long term management of his anticoagulation and also any recommendations you would have about rhythm control.  He is in normal sinus rhythm as of my evaluation of him on 06/12/2008.  He is tolerating his metoprolol and aspirin without any difficulty.  I guess the big question remains is what level of risk that is entailed by placing him on Coumadin therapy due to his potentially paroxysmal atrial fibrillation and evidence of left atrial enlargement that would place him in increased risk of recurrent episodes.,I appreciate your input regarding this friendly gentleman.  His current medicines include penicillamine 250 mg p.o. four times a day, metoprolol 12.5 mg twice a day, and aspirin 325 mg a day.,If you have any questions regarding his care, please feel free to call me to discuss his case.  Otherwise, I will look forward to hearing back from you regarding his evaluation.  Thank you as always for your care of our patient.letters, atrial enlargement, wilson's disease, penicillamine,