DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with a history of hypertension, insulin-dependent diabetes, and hypothyroidism who presented to the emergency room after an episode of syncope. The patient describes having had two episodes of syncope and developed an occipital hematoma from the first episode. These episodes were not preceded or accompanied by any chest pain, diaphoresis, palpitations or urinary incontinence.
The patient presented to the emergency room, and upon initial evaluation, she was found to be awake, alert, and oriented x3, and her vital signs in the emergency room were found to be temperature 97.2, pulse 82, respirations 20, blood pressure 162/80, and O2 saturation 97%. In the emergency room, she had an EKG, which failed to reveal any kind of arrhythmia and no acute changes. She was then admitted for further monitoring and workup to the telemetry unit.
PAST MEDICAL HISTORY: Already mentioned in the history of present illness but also includes hypercholesterolemia. She also has a history of diverticular bleed several years ago and a history of a fracture of the left tibia, which was followed by an episode of DVT.
MEDICATIONS: Humalog, Lantus insulin, Avandia, Synthroid, Prinivil, Zetia, one baby aspirin, multivitamins, and p.r.n. sublingual nitroglycerin.
ALLERGIES: She reports allergy to most antibiotics.
SOCIAL HISTORY: The patient does not smoke, drink or use any drugs. She is married and has a supportive family.
FAMILY HISTORY: Significant mostly for hypertension and diabetes.
REVIEW OF SYSTEMS: On admission, she really had no complaint, except for some tenderness in the occipital area where she had developed the little hematoma.
PHYSICAL EXAMINATION: GENERAL: On admission, elderly female, in no acute distress. VITAL SIGNS: Blood pressure 140/66, pulse 80, respirations 18, and O2 saturation 97%. HEENT: Pupils equal and reacting to light. Extraocular movements full. There was no jaundice. A small hematoma was present in the occipital area. NECK: JVP was flat. There was no lymphadenopathy and no thyromegaly. There was a thyroidectomy scar. LUNGS: Clear. HEART: Regular without any gallop, murmur or rub. ABDOMEN: Soft. There was no organomegaly, no ascites, no guarding, no rebound. EXTREMITIES: No edema. NEUROLOGIC: Nonfocal.
ADMITTING LABORATORY DATA: Cardiac enzymes were negative. TSH was 0.532. BNP was 304. CBC was within normal limits. EKGs showed RSR, right bundle branch block, and some inferior ischemia. The patient was evaluated by Electrophysiology and by Cardiology. Enzymes remained negative.
HOSPITAL COURSE: The patient was scheduled for a tilt test and a His bundle study, which were performed. The tilt test was significant for the patient feeling dizzy and weak and a blood pressure of 82/62 six minutes after nitroglycerin. Then, she also felt nauseated and diaphoretic and became near syncopal with a weak pulse, and she was put back in the supine position, where her blood pressure became 132/68 with a heart rate of 72.
The recommendation was that she undergoes a cardiac cath and also an electrophysiologic study. She remained asymptomatic with a blood sugar oscillating between 90 and 160. On MM/DD/YYYY, she underwent cardiac catheterization, which showed nonobstructive coronaries with normal LV function, mildly elevated left ventricular end diastolic pressure, no aortic stenosis, and subsequently underwent a His bundle electrogram on MM/DD/YYYY. The His bundle electrogram was performed, and it showed normal sinus node function, normal AV node function, no evidence of dual AV node physiology. There was normal His Purkinje function. No evidence of infra-His block with rapid atrial pacing and also there was no inducible atrial arrhythmia.
It was decided to discharge her on Toprol and no permanent pacemaker was felt to be necessary. Upon discharge, the patient said she was very sensitive to Toprol, becoming very tired when prescribed this medication in the past. She was given pindolol at 5 mg p.o. daily, and she was discharged on MM/DD/YYYY to present to her PMD within a week for followup.
