An 87-year-old man with a history of mild dementia on Aricept and hypertension on benazepril is brought to the emergency department by family after a possible fall. His daughter came to visit and found him sitting up against a wall in his bedroom and thinks he may have fallen, but saw no injuries. She says that has seemed more tired and more forgetful than normal over the past week and it has been getting progressively worse. It wasn’t that noticeable until today, so she had just been keeping tabs on him, but now she wants him checked out.
The patient and the daughter both deny that there has been any fever, vomiting, pain, trouble breathing, or other complaints. The daughter says that he lives alone and has been able to continue managing his affairs with only minimal outside help. Other than the medications listed above he is only taking vitamins and occasional Pepcid for acid reflux.
The patient’s vital signs were all normal with a pulse in the 60s. However, while you are in the room you notice that the heart rate on the cardiac monitor occasionally drops for 5-10 seconds down into the 40s and even the 30s.
The patient seems to be a bit lethargic but follows command. The rest of his physical exam is otherwise unremarkable except for his memory being 2 out of 3 items at 2 minutes.
• Head injury
• Heart block
• Blood and urine unremarkable
• CT head normal
• ECG – see tracing in Figure 1 at right (please click to enlarge)
1. What does the ECG tracing show?
2. What should you do next?
Please click below for answers and discussion.