Progress Notes on a patient with Sinus Bradycardia

Progress Notes on a patient with Sinus Bradycardia

History of presenting Illness

The patient is a 66-year-old female who had been reviewed by a  physician and referred for a cardiologist review. She reports that for the past few weeks, she has been experiencing general body weakness, feeling lightheaded, and dizziness. She also reports intermittent chest pains. The last chest pain occurred approximately five days ago. She describes the pain was at the substernal with no association to exertion.

She reports having had dyspnea on exertion during the last two weeks. During her review, she denied any chest pains or dyspnea. She also denies any recent orthopnea or nocturnal dyspnea. She reports no coughs, fevers, or chills. She denies having dysuria though she has been on Keflex for treatment on urinary tract infection.

Past Medical, Family and Social History

The patient has been on treatment for chronic obstructive pulmonary disease, type II diabetes mellitus, hypertension, and stage III chronic renal disease. She had a history of hysterectomy ten years ago. She is on several medications, as listed. Lasix 40 mg daily, Coreg 6.25 mg b.i.d, Lipitor 10 mg daily, gemfibrozil 600 mg p.o. b.i.d., buspirone 7.5 mg b.i.d., ProAir inhaler p.r.n., Keflex 500 mg p.o. q.i.d., aspirin 81 mg daily, levothyroxine 50 mcg daily, NovoLog sliding scale, losartan 100 mg daily, Lantus 30 units subcutaneous b.i.d., loratadine 10 mg daily, Singulair 10 mg at bedtime, Lyrica 50 mg b.i.d. and 75 mg at bedtime, fish oil 1000 mg b.i.d., potassium chloride 8 mEq daily, trazodone 50 mg daily, and Protonix 40 mg daily. She has no history of any allergies to medications. There is a positive history for cardiomyopathy in her mother and coronary artery disease and hypertension in her sister and brother, respectively. She admits to smoking a pack a day, no history of alcohol intake, nor illicit substance abuse. The patient is obese; she admits to taking fast foods and having a sedentary lifestyle.

Examination

On examination, the Blood pressure was 170/92 mmHg, the heart rate was 47beats/minute regular, the temperature was 97^oF, respiratory rate of 19 breaths/ minute, and the oxygen saturation at 95% on room air. On physical exam, there were no abnormalities except for the regular Bradycardia and bilateral ankle edema.

The chest X-ray revealed no acute cardiopulmonary abnormalities. The 12- lead EKG before referral had shown AV junctional Bradycardia with the heart rate of 36 beats/ minute. A repeat EKG done at the office showed sinus bradycardia with the heart rate at 49 beats/ minute. The lab results included: Cardiac markers were negative x1, BNP was 846. Normal liver function test, normal electrolyte levels. The BUN was 48 mg/dl, and the Creatinine levels were 2.0 mg/dl. The last creatinine level done last year was 1.7mg/dL. The GFR is 34 ml/min/1.73m². The PT and INR are within the normal range. The TSH was at 1.06 mIU/L.

Clinical Assessment/ Impression

The first impression is Sinus bradycardia which can be caused by:

1. Hypothermia: Hypothermia causes a decrease in the depolarization of the Sinus, which leads to Bradycardia (Livingston & Overton, 2017). In this patient, however, the body temperature is 97^oF, which is within the normal range.
2. Hypothyroidism: the low levels of thyroid hormones causes a decrease in the heart rate. It also causes a decrease in the arterial wall elasticity, as a compensatory mechanism, it causes an increase in the blood pressure to increase the blood circulation. It also causes body weakness and fatigue (Livingston & Overton, 2017). However, in this case, TSH levels are within the normal range despite having a history of hypothyroidism and treatment.
3. Sinus bradycardia caused by beta-blockers: Beta-blockers cause a reduction in action potential regeneration as well as atrioventricular conduction. They act on the sympathetic nervous system causing adverse chronotropic and inotropic effects. This leads to a reduction in the heart rate (Livingston & Overton, 2017).

The second impression is dyspnea on exertion with unknown etiology. She has a history of COPD; however, the average oxygen saturation on room air and no respiratory abnormalities on examination rule out any exacerbation of the COPD.

She also has chronic renal disease in stage III to IV. Symptoms include bilateral edema of the extremities and high levels of serum urea and creatinine levels. All of which is consistent with our patient.

Plan of treatment

1. The patient required admission for close monitoring on telemetry. Treatment of Sinus tachycardia will also include putting the beta-blocker on hold. She will be given transcutaneous pacing intravenous atropine as needed. Monitoring of the cardiac markers and repeat 12 lead EKG, as well as an echocardiogram, is vital during follow up for consideration of pacemaker placement. The patient will be educated on lifestyle changes as well as healthy diets. The patient also has to stop smoking (Schulman, 2019).
2. The echocardiogram and the troponin monitoring are vital as the patient is at high risk of Coronary artery disease. A stress test is also essential due to the chest pain experienced by the patient (Schulman, 2019).
3. Since her creatinine levels are close to her baseline, she can continue with her medications. She needs to have strict follow up and also avoid nephrotoxic medications and also include lifestyle changes to manage her conditions.
4. She will continue with the insulin according to the sliding scale. This will help manage her glycemic levels and prevent the complications caused by diabetes. She also requires dietary changes that support blood sugar control.
5. The hypothyroidism she will continue with levothyroxine.
6. She will continue with her antihypertensive medications, except for Coreg, which will be put on hold.
7. She will continue with the statin to manage hyperlipidemia. She also needs to adhere to healthy eating and lifestyle changes. (Livingston & Overton, 2017)

References

Jabbour, F., & Kanmanthareddy, A. (2020). Sinus Node Dysfunction. Retrieved July 8, 2020, from PubMed website: https://www.ncbi.nlm.nih.gov/books/NBK544253/

Livingston, M. W., & Overton, D. T. (2017, December 27). Sinus Bradycardia Differential Diagnoses. Retrieved July 8, 2020, from emedicine.medscape.com website: https://emedicine.medscape.com/article/760220-differential

Schulman, J. S. (2019, September 26). Sinus Bradycardia: Symptoms, Diagnosis, and Treatments. Retrieved July 8, 2020, from Healthline website: https://www.healthline.com/health/heart-disease/what-to-know-about-sinus-bradycardia#diagnosis

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