Blackout at Rest and Slurring in a Man Afraid of COVID-19

Ankit Raiyani, MBBS, MD, DNB (Hematology)


March 03, 2021

Physical Examination and Workup

Upon examination, the patient is alert and oriented but appears fatigued. He is afebrile. He has bilateral pitting pedal edema, which does not extend above the ankles, and periorbital edema. No icterus, lymphadenopathy, cyanosis, or clubbing is noted. Examination of the oral cavity shows macroglossia with teeth indentations. Skin examination findings are unremarkable except for the presence of ecchymoses.

Auscultation of the chest reveals a respiration rate of 24 breaths/min, with inspiratory crepitations at the bases of the lungs. His pulse is regular at 82 beats/min (after reverting to sinus rhythm), and his blood pressure is 108/64 mm Hg (supine) and 90/56 mm Hg (standing). His abdomen is distended but nontender. No hepatomegaly or splenomegaly is noted. A dull percussion note is elicited on the flanks. Neurologic examination findings are normal and reveal no focal deficits.

The patient's complete blood cell count is suggestive of normocytic anemia, with a hemoglobin level of 10.5 g/dL (reference range, 13.5-15.5 g/dL). The leukocyte count with differential and platelet count are within normal limits. Results of a peripheral smear examination are unremarkable.

The patient has an elevated serum creatinine level of 1.91 mg/dL (reference range, 0.9-1.3 mg/dL). Serum electrolyte levels (including sodium, potassium, calcium, and magnesium) are normal. Liver function test results are largely within normal limits, except for these serum protein values:

  • Total protein: 4.1 g/dL (reference range, 6.4-8.3 g/dL)

  • Albumin: 1.8 g/dL (reference range, 3.5-5 g/dL)

  • Globulin: 2.3 g/dL (reference range, 2.3-3.4 g/dL)

No monoclonal bands are detected on serum protein electrophoresis.

The findings on a two-dimensional echocardiogram suggest fair left ventricular systolic function, with a left ventricular ejection fraction of 60%. The chief findings are an interventricular septal thickness of 18 mm and grade 3 diastolic dysfunction. The patient has a very high N-terminal pro-brain natriuretic peptide (NT-proBNP) level of 24,924 pg/mL (reference range, < 300 pg/mL). His troponin I level is 0.38 ng/mL (reference range, < 0.03 ng/mL). Multiple short runs of ventricular premature complexes are detected by 24-hour ambulatory electrocardiographic (Holter) monitoring.

Urine examination reveals proteinuria without casts. No hematuria is detected. A 24-hour urinary protein loss of 7.1 g is noted (reference range, < 150 mg/d).

An ultrasonogram reveals marked mesenteric edema throughout the abdomen but no organomegaly or lymphadenopathy. An ultrasonogram of the pelvis shows bilateral bulky kidneys, with the loss of corticomedullary differentiation. No hydronephrosis or nephrolithiasis is observed.


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