DISCHARGE DIAGNOSES:
1. Severe bradycardia with 3.2 second pauses.
2. Atrial fibrillation.
3. Hypertension.
4. Sick sinus syndrome.
5. Status post single chamber St. Jude pacemaker implantation.
HOSPITAL COURSE: The patient was admitted electively for placement of a permanent pacemaker. The patient was recently evaluated in the office with complaint of dizziness. A Holter monitor was performed, which revealed atrial fibrillation with rapid ventricular response alternating with severe bradycardia and pauses of more than 3.2 seconds. In view of this, the decision was to proceed with permanent pacemaker implantation. The patient underwent the procedure without any complications.
PHYSICAL EXAMINATION: The patient is alert and oriented x3, not in acute distress. Skin is intact. No rashes. The left subclavicular area looks well. There is no evidence of oozing, swelling, hematoma or pain. HEENT: Normocephalic and atraumatic. Extraocular movements intact. Neck: No jugular venous distention. Bilateral faint carotid bruits. Cardiovascular: Regular rhythm and rate. S1, S2, 2/6 holosystolic murmur. Respiratory: Clear to auscultation bilaterally. Good air entry bilaterally. Abdomen: Soft, nontender and nondistended. Bowel sounds are present. Extremities: No clubbing, cyanosis or edema. Bilateral +2 femoral pulses. Neurologic: Examination is grossly nonfocal.
EKG reveals ventricularly paced rhythm. Laboratory data is within normal limits.
ASSESSMENT: The patient is a (XX)-year-old male with history of atrial fibrillation who was found to have sick sinus syndrome and severe bradycardia requiring implantation of a permanent pacemaker.
PLAN:
1. We had a long conversation with the patient and his wife regarding the fact that his blood pressure was somewhat out of control when he was in the hospital. It was ranging up to 160s-170s/90s. It did not seem to respond adequately to his current dose of Altace 5 mg p.o. daily. We would like to increase this to 5 mg p.o. b.i.d. The patient was also instructed in consuming less than 2-gram sodium diet and given extensive instructions and a pamphlet of less than 2-gram sodium diet from the American College of Cardiology.
2. We will also restart his Coumadin today with 10 mg, and starting tomorrow, he will start taking 7.5 mg daily, which is the current dose that he takes at home. He was instructed to check his INR in the office within the next week.
3. The patient was also given ample instructions regarding the limitations of motion of his left arm over the next 2 weeks as well over the next 4 weeks. He will be following up with us in the office within the next 2 to 3 weeks, at which time we will proceed with a permanent pacemaker check.
4. The St. Jude representative was in today and checked the pacemaker revealing excellent function. The patient was also instructed to come here anytime with any further questions or concerns. He will be undergoing further evaluation for his cardiac murmur and carotid bruits with an echocardiogram and a carotid ultrasound, which will be performed over the next week as an outpatient.
