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A 72-year-old man is brought to the emergency room after fainting while in church. He had stood up to sing a hymn and then fell to the floor. His wife, who witnessed the episode, reports that he was unconscious for approximately 5 minutes. When he awakened, he was groggy for another minute or two, then seemed himself. No abnormal movements were noted. This has never happened to him before, but his wife does report that for the last several months he has had to curtail activities, such as mowing the lawn, because he becomes weak and feels lightheaded. His only medical history is osteoarthritis of his knees, for which he takes acetaminophen.
On examination, he is alert, talkative, and smiling. He is afebrile, his heart rate is regular at 35 bpm. and his blood pressure is 118/72 mmHg, which remains unchanged on standing. He has contusions on his face, left arm, and chest wall, but no lacerations. His chest is clear to auscultation, and his heart rhythm is regular but bradycardic with a nondisplaced apical impulse. He has no focal deficits. Laboratory examination shows normal blood counts, renal function, and serum electrolyte levels, and negative cardiac enzymes. His ECG is shown in Figure 15-1.
^ What is the most likely diagnosis?
^ What is your next step?
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