Sick Sinus Syndrome Discharge Summary Sample Report
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
FINAL DIAGNOSIS: Sick sinus syndrome.
SECONDARY DIAGNOSES:
1. Syncope.
2. Diabetes mellitus type 2.
3. Hypertension.
4. Dementia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with a past medical history of diabetes mellitus, hypertension, rheumatic heart disease, aortic stenosis, mitral regurgitation, and status post CVA x2 who came to the emergency department after the patient fell. As per the patient’s at-home aide, the fall was heard, however not witnessed by anybody. Upon arrival to the site where the patient fell, she was found on the floor only for a few seconds. Otherwise, no other complaints.
Because the patient was a poor historian, most of the history was taken from the medical records. As per the medical records, the loss of consciousness was preceded by dizziness, and after the fall, the patient came back to baseline consciousness within minutes of the episode. The patient denied headaches, chest pain, shortness of breath or palpitations.
PAST MEDICAL HISTORY: Diabetes mellitus type 2, hypertension, rheumatic heart disease with aortic stenosis and mitral regurgitation, CVA x2, and dementia.
MEDICATIONS: Digoxin, Coreg, Lasix, glyburide, and Coumadin.
ALLERGIES: NKDA.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives at home with a 24-hour home aide. She denied smoking or alcohol.
REVIEW OF SYSTEMS: As above. In addition, the patient denied fever, denied cough, denied dyspnea, denied headaches, and denied recent sick contacts.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.6 degrees, pulse 78 and irregular, respiratory rate 20, blood pressure 164/68, and pulse oximetry 96% on room air. GENERAL APPEARANCE: The patient is a (XX)-year-old, age appropriate-looking female, lying in bed, oriented to person, however not oriented to time or place. The patient appeared to be confused and lethargic; however, gave appropriate responses occasionally. HEENT: No conjunctival pallor. Extraocular movements are intact. The patient had left eye cataract surgery. NECK: Supple. No adenopathy. No thyromegaly. No JVD. LUNGS: Good air entry bilaterally. The patient had decreased inspiratory efforts. No rales. No rhonchi. HEART: S1 and S2 heard. The patient had a 3/6 systolic ejection murmur on the aortic focus and a 3 to 4/6 systolic murmur on the mitral focus radiating to the axilla. ABDOMEN: Soft, nontender, and nondistended. Positive bowel sounds. There was a positive oblique scar noted in the right upper quadrant. EXTREMITIES: No clubbing. No calf tenderness. No edema. Pulses 2+ bilaterally. NEUROLOGICAL: Cranial nerves II through XII were intact. Muscle strength was difficult to assess secondary to the patient’s mental status. DTR 2+ on upper extremities bilaterally and 1+ on lower extremities bilaterally.
LABORATORY AND DIAGNOSTIC DATA: CBC revealed white count 9800, hemoglobin 15, hematocrit 45.2, and platelets 270,000. Chemistry showed sodium 137, potassium 5.2, chloride 100, bicarbonate 24, BUN 16, creatinine 0.8, blood sugar 226, total protein 7.8, albumin 3.9, total bilirubin 1.3, alkaline phosphatase 126, SGPT 52, SGOT 64. Troponin, first set, 0.024. INR 3.1. Digoxin level was 0.7. Chest x-ray was read initially as no acute infiltrates. EKG showed atrial fibrillation with a ventricular rate of 100 beats per minute. No ST-T changes. A head CT showed old infarcts and age-related changes. No acute process.
HOSPITAL COURSE: The patient was admitted to telemetry with the initial diagnosis of syncope, cardiac versus neurogenic, and the following medications were started: Lasix 40 mg p.o. daily, Coreg 12.5 mg p.o. b.i.d., Coumadin 2.5 mg p.o. daily, and digoxin 0.125 mg p.o. daily. During her stay, the following tests were ordered in addition to the ones done in the ER. A 2-D echo was done, which showed a fair LV function with aortic stenosis and mitral regurgitation, and carotid duplex was done, which showed 15-49% occlusion bilaterally.
In addition, telemetry monitoring showed that the patient was having atrial fibrillation with ventricular pauses for which cardiology and electrophysiologic study consults were called. After evaluating the patient, EPS and the cardiologist concluded that the patient would benefit from a permanent pacemaker because of the ventricular pauses, which were likely the etiology of the syncope. For these pauses, while the patient was waiting for the pacemaker placement, Coreg and digoxin were both held in addition to Coumadin, which was also held for the procedure. For the patient’s diabetes mellitus, glyburide was held, and the patient was placed on a regular insulin sliding scale with moderate control of the blood sugars.
Finally, the day before discharge, the patient underwent a pacemaker implant. After 24 hours of telemetry monitoring, it was determined that the patient had ventricular pacing without any pauses, and therefore, it was decided to discharge the patient home, mainly because the patient had a 24-hour home aide.
DISCHARGE CONDITION: Fair.
FOLLOWUP: Followup was to be done by the patient’s primary care physician within one week of discharge.
DISCHARGE ACTIVITY: As tolerated with fall precautions.
DISCHARGE DIET: As tolerated by the patient.
DISCHARGE MEDICATIONS: The patient was to be discharged on Lasix 20 mg p.o. daily. The patient was to continue glyburide at unchanged dose from previous to admission; however, the patient was to stop Coreg, digoxin, and Coumadin until further advice from the patient’s primary care physician.
