Age: 57.0
Sex: M
Vaccine: COVID19
Symptoms: Electrocardiogram normal, Fall, Fatigue, Hyperhidrosis, Impaired work ability
Clinical narrative: Patient admitted with high grade AV block, sinus pause, and recurrent syncope. 57-year-old white male with PMH only of cigarette use who notes about 2 weeks of generalized malaise, then in the last 24 hours has had 2 syncopal episodes that were accompanied by diaphoresis only without other prodrome.  He got his second dose of Moderna COVID-19 vaccine on 5/28/21, then on the following day had been working in the barn without any dyspnea chest pain or shortness of breath but felt generally fatigued so went to take a nap.  He got up to check his temperature, then "just hit the floor".  Not preceded by blackout of vision, lightheadedness, chest pain, dyspnea palpitations, nausea but was accompanied by sweats.  He believes he was out only briefly, and when he awoke was not confused and did not have tongue biting or loss of bladder or bowel continence.  He then got up and went about his day normally, then around 2 AM awoke to let the dogs out and had an identical event, but this time hit his chin on a chain saw on the floor and suffered a laceration. He presented to ED for evaluation where his laceration was sutured. He is hemodynamically stable and afebrile. Initial labs and diagnostics are unrevealing and an EKG showed a normal sinus rhythm without acute or chronic ischemic changes.  Noncontrast CT of the head and the face showed no evidence of bony damage, no intracranial bleed or large territory infarct. While in the ED, the patient had a brief bradycardic episode accompanied by diaphoresis although a dedicated strip is not available and it is unclear what his rhythm was.  He did not syncopize.  Hospitalist service was asked to accept for syncope evaluation. When admitting physician saw patient, he reported feeling completely well without any other issues.  He does note he had about 2 weeks of malaise before all of this started and a mild decrease in his ability to work intensely, but had attributed this to cigarette smoking.  Review of systems was essentially negative.  He is a hobby farmer and has had a couple of tick bites this year. While admitting physician was in the room at the end of the visit, the patient had an episode of diaphoresis and went into a high-grade second-degree AV block with disappearance of atrial activity without ventricular escape and lost consciousness for about a second.  No jerking or twitching observed.  The episode a couple of seconds then self terminated and the patient awoke and completely recovered mentation and was in a sinus rhythm.  He was diaphoretic and felt ill afterward this.  He had no chest pain or dyspnea. Immediately after the episode with repeat vitals the patient's heart rate was in the 70s and a normal sinus rhythm and blood pressure is 136/80.  Oxygen saturations are preserved. Not on any rate limiting agents either here in emergency department or at home. Patient found to have P-P interval prolongation with AV block and subsequent sinus arrest possibly situational in the setting of coming off of a colonoscopy and receiving second Moderna COVID-19 vaccine. A pacemaker was placed 6/1/2021 without complication and the patient was discharged in stable condition on 6/2/2021.