Case Report: Slow AFib?

History:

An elderly male with a past medical history of diabetes and stage 5 chronic kidney disease is brought to the hospital by medics with 2 days of nausea, vomiting and generalized weakness. He denies any chest pain, difficulty breathing, fever, chills, abdominal pain, diarrhea, melena, or other complaints. He has a dialysis fistula but has not yet started dialysis. His home medications include losartan, amlodipine, Lasix, sitagliptin, and Plavix.

Exam:

He is normotensive however heart rate is in the 20–30s range. His extremities are warm and well perfused with a palpable thrill in the left arm. He is not confused. He has faint crackles in the bases bilaterally with trace lower extremity edema.

Computer Read: Atrial fibrillation at 24, marked LAD, RBBB