89 year old gentleman with history of Syncope - What should be the next step in management ?

A 89 years old gentleman with a history of hypertension and osteoarthritis presents to the ED with an episode of syncope while listening to music. He has felt generally lethargic for the past one week. He denies  chest pain, shortness of breath, or fever. His medications include Metoprolol and celecoxib. The blood pressure is 120/60 mmHg, H/R 42/min, R/R 15/min, and he is afebrile. His physical examination reveals normal lung sounds, a regular, bradycardic rhythm with varying intensities of the S1 heart sound on auscultation, and intermittent large cannon A waves in the jugular venous pulsation. His laboratory studies are normal. The ECG of the patient is depicted below. What is the next step in management of this patient?

 A) Observation

 B) Stop Metoprolol

 C) Permanent pacemaker implantation

 D) AICD Implantation

Answer-
Diagnosis -2nd degree AV block - high grade - Mobitz II 
Next Step in Management - Stop Metprolol and be ready for PPI 

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