Patient underwent bivalvular mechanic mitral- aortic valve replacement 13 years ago. She had a history of type 2 diabetes mellitus and chronic kidney disease (eGFR of 12 ml / min). An 81-yearold woman was admitted to our institution with bradycardia, weakness and presyncope. We report a case where moderate hyperkalemia caused pacemaker exit block and a failure of ventricular pacemaker capture. Occasionally failure to capture appears at a lower level, especially in the presence of heart disease. When the K level reaches 7 mEq / L pacing thresholds could increase, with or without increased latency. When the K level increases, the intraventricular conduction velocity is decreased and the paced QRS complex widens. Hyperkalemia is a life threatening metabolic condition. Our patient showed a moderate acute hyperkalemia, which caused pacemaker exit block and capture failure. Analytic test showed a creatinine 3.78 mg / dl, Urea 187 mg / dl, sodium 133 mEq / L, potassium 6.2 mEq / L, and pH 7.37. The interrogation of the device showed a correct ventricular sensing and a threshold for ventricular pacing of 6.5 V at 1 ms pulse width. At admission physical examination revealed a pulse rate of 42 per minute, blood pressure of 95 / 50 mmHg, and an oxygen saturation of 93 % on room air. Submitted: 07 October 2015 Accepted: 18 November 2015 Published: 28 November 2015 AbstractĪn 81-year-old woman was admitted to our institution with bradycardia, weakness and presyncope. I expect that you will improve your performance and try to meet the company’s expectations.Pau Alonso *, Raquel Lopez, Maria Jose Sancho-Tello, Ana Andrés, Óscar Cano, Joaquín Osca and Jose Olagüeĭepartment of Cardiology, Electrophysiology Section, La Fe University Hospital, Valencia, Spain Corresponding Author: Pau AlonsoĮlectrophysiology Section, La Fe University Hospital However, if the company finds that you don’t change your behavior and take your responsibilities seriously, the company holds all the right to terminate you from the job. Your late submission of work and other sorts of misconduct have been ignored several times. I would like to reiterate here that the company can never be in favor of tolerating those people who don’t fulfill their job roles. When I asked you to provide me with the explanation letter to explain why you did show up, you did not respond.Īccording to the terms and policies of the company, any person who fails in fulfilling the job responsibilities that are assigned to him is deemed incompetent. When the submission date reached, you did not show up and you also did not attend my phone call.
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You are aware of the culture of the company according to which, employees are expected to finish their work by the said deadline. But, I am so disappointed to see that you have still not completed your work. You were assigned a task last month and I was expecting you to complete it within the period of one month. It seems like you are failing in performing your duties well. You are not working up to the criteria and neglect is being seen time and again.
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Non-stop mistakes at your end are stressful for everyone at the workplace. You have also been asked to show up at the workplace on time. Your manager has told me that has admonished you so many times for delivering the assigned work on time. I discussed this with your manager yesterday and I came to know that you are consistent in terms of performing poorly. However, make sure that you close the letter on a very positive note. In the third section of the letter, warn the employee without being rude and also tell him that you have the authority to take action against him if he fails to perform his duties well.
![failure to capture failure to capture](http://www.medicalexhibits.com/obrasky/2013/13286_05X.jpg)
In case the employee does not know that he is being monitored continuously, this letter will help him better understand everything.