66-Year-Old Man With Light-headedness, Chest Pain, and Dyspnea

Abstract

A 66-year-old white man with a medical history of chronic kidney disease (CKD) stage 3a (baseline creatinine level of 1.4 mg/dL; normal 0.74-1.35 mg/dL) with an estimated glomerular filtration rate of 52 mL/min per 1.73 m 2 per the Chronic Kidney Disease Epidemiology collaboration equation, controlled type 2 diabetes mellitus with microalbuminuria, hypertension, hyperlipidemia, and medically complicated obesity (body mass index, 37) presented to his primary care clinic with episodes of orthostatic light-headedness that had been occurring for approximately 2 weeks. These episodes were also associated with chest tightness and dyspnea. Symptoms occurred only while standing or ambulating and never while at rest. He reported no palpitations, vertiginous symptoms, recent fevers or chills, hemoptysis, known sick contacts, or insect bite exposures. His lightheadedness, chest pain, and dyspnea worsened on the day before presentation, prompting a visit to his physician for further evaluation. He reported that he had been taking his blood pressure medications including amlodipine, lisinopril, atenolol, and spironolactonehydrochlorothiazide, as well as his other medications (metformin, aspirin, and pravastatin) regularly and as instructed. He had noted a considerable decrease in his urine output over the previous day. He had no recent travel, surgical procedures, immobilization, history of pulmonary embolism (PE), deep venous thrombosis, or active malignancy.On physical examination, he appeared nontoxic but had bradycardia (heart rate, 25 beats/min) with hypotension (blood pressure, 90/40 mm Hg) and a respiratory rate of 14 breaths/min. No rashes, lymphadenopathy, or peripheral edema were noted. Heart examination revealed no murmurs, and lung examination findings were normal. He was alert and in no distress. Results of abdominal examination and the remainder of the neurologic examination were unremarkable. Given his severe symptomatic bradycardia and borderline hypotension, he was referred to the emergency department (ED) for further evaluation.