A 67-Year-Old Woman With Orthostatic Hypotension and Edema

Catherine Anastasopoulou, MD, PhD; Kimberly Lessard, DO


March 08, 2018

Physical Examination and Workup

Upon physical examination, the patient is an ill-appearing, overweight woman in mild distress. Her vital signs upon arrival included a blood pressure of 106/59 mm Hg, a heart rate of 73 beats/min, an oral temperature of 97.3°F (36.3°C), oxygen saturation level of 94% on room air, weight of 150 lb (68 kg), and a body mass index of 29.3. Upon standing, the patient develops signs of orthostatic hypotension with significant dizziness, lightheadedness, and a drop in systolic blood pressure to 92 mm Hg.

The examination of the head and neck reveals dry mucus membranes. Cardiopulmonary examination findings are within normal limits, with normal S1 and S2 sounds, a regular heart rate and rhythm, and no appreciable murmur or jugular vein distention. Abdominal examination reveals slightly diffuse abdominal tenderness with normal bowel sounds and no hepatosplenomegaly. A neurologic examination reveals no significant deficit. She is noted to have +1 pitting edema in both lower extremities to the level of the knee with associated tenderness and decreased flexion of both joints. Her skin appears dry without appreciable tenting, bruising, or any lesions.

The initial workup includes an EKG, which reveals normal sinus rhythm without ST-T changes. A chest x-ray is noncontributory, and CT scanning of the chest is performed, which is negative for pulmonary embolism. Results of the initial chemistry are as follows:

  • Sodium level—134 mmol/L (reference range, 136-146 mmol/L)

  • Potassium level—4.9 mmol/L (reference range, 3.6-5.1 mmol/L)

  • Chloride level—101 mmol/L (reference range, 98-107 mmol/L)

  • Bicarbonate level—23 mmol/L (reference range, 22-31 mmol/L)

  • Blood urea nitrogen level—22 mg/dL (reference range, 10-20 mg/dL)

  • Creatinine level—0.5 mg/dL (reference range, 0.6-1 mg/dL)

  • Glucose level—143 mg/dL (reference range, 74-99 mg/dL)

  • Magnesium level—1.4 mg/dL (reference range, 1.6-2.6 mg/dL)

A complete blood count is significant for normocytic anemia with a hemoglobin level of 10.7 g/dL (reference range, 12-16 g/dL) and mean corpuscular volume of 85.4 fL (reference range, 81-96 fL); all other values are within normal limits. Her international normalized ratio is 2 IU (reference range, 0.9-1.1 IU), her prothrombin time is 22.7 s (reference range, 11.8-14.3 s), and her partial thromboplastin time is 52.1 s (reference range, 25.5-36 s). Serial troponin findings are negative; however, the brain natriuretic peptide is elevated at 150.2 pg/mL (reference range, <100 pg/mL). Her serum osmolality is 273 mOsm/kg, and her urine sodium level is 41 mmol/L.

The patient is admitted for further workup and is treated with continuous intravenous (IV) normal saline (0.9% at 120 cc/h) as well as IV magnesium. Despite fluid resuscitation, however, she remains borderline hypotensive (96/59 mm Hg) with persistent orthostatic symptoms. Continuous telemetry monitoring reveals occasional bradycardia. Transthoracic echocardiography reveals intact ejection function and only grade 1 diastolic dysfunction. Subsequent laboratory evaluation is significant for a vitamin B12 level of 512 pg/mL (reference range, 213-816 pg/mL), thyroid-stimulating hormone level of 2.29 mcIU/mL (reference range, 0.35-4.94 mcIU/mL), folate level of 4.6 ng/mL (5.4-20 ng/mL), vitamin D 25-OH level of 45.9 ng/mL (reference range, 30-50 ng/mL), and early (05:00) cortisol level of 0.8 (reference range, 3.7-19.4 µg/dL). An infectious workup, including urine studies and blood cultures, is negative.

Repeat chemistry after 24 hours of IV fluids reveals the following:

  • Sodium level—138 mmol/L

  • Potassium level—4.3 mmol/L

  • Chloride level—103 mmol/L

  • Bicarbonate level—25 mmol/L

  • Blood urea nitrogen level—15 mg/dL

  • Creatinine level—0.5 mg/dL

  • Glucose level—115 mg/dL (reference range, 74-99 mg/dL)

  • Magnesium level—1.5 mg/dL

The CT pulmonary embolism study from her prior hospitalization is subsequently obtained (see Figures 1-2 below).


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