You are the resident on call and you have your first admission of the night. She is a 76 year old female presenting to the ER with chief complaint of "syncope and "dizzyness". Patient says she was going through her normal breakfast routine when she was standing up and suddenly "blacked out" and fell to the floor. Her husband states she did not loose conciousness, did not become incontinent and she immediately regained conciousness after about 20 seconds being on the floor. After the fall her husband put her on the couch and she has been complaining of light headedness ever since. CT was done to rule out any trauma to the head and was negative. Past Medical history significant for Coronary Artery Disease, Hypertension, Rhematoid Arthiritis and osteoperosis. No focal neurologic signs, and physical exam was with in normal limits except for a pulse of 55 and BP of 90/45. Patient was unable to tolerate orthostatics. A stat EKG was done and here it is below. What is your diagnosis and what is the next step in management.

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Explanation

Looking at the rhythm strip the qrs complexes are regular. However there are no p waves before each one and what may be confused for a T than a U wave. What actually is present an inverter p wave than the T wave. This is a junctional pacemaker with the pacemaker being low enough on the bundle of his that the retro-conducted p waves are not burried in the QRS and are actually clearly seen after it. Also we can safely say that these are retro-conducted because in II, III and AvF the p waves are in the opposite direction of what they should be if they were from the sinus node. There is also a left axis deviation due to the fact that the pacemaker is located low on the bundle of his creating a "left anterior fasicular block pattern". So it can be either from the high Left poster fascicle or the high right bundle.

The next step would be to get a EP consult for possible pacemaker in plantation if sinus rhythm could not be reestablished.