A 76-year-old African American male with a past medical history significant for coronary artery disease, diabetes mellitus, unilateral severe carotid artery stenosis, and chronic kidney disease stage IIIb presented to the emergency department after an unwitnessed syncopal event. He was making breakfast when he lost consciousness. He denied any palpitations or prodromal symptoms. He regained consciousness almost immediately and denied postictal confusion. He also denied any tongue biting or loss of bowel/bladder contents.
He was afebrile with a blood pressure of 113/61 mmHg, heart rate of 67 beats per minute, respiratory rate of 18 and his oxygen saturation was 99% on room air. On physical exam lungs were clear to auscultation bilaterally. His heart had a regular rate and rhythm, normal S1 and S2 without any murmurs appreciated.
His initial labs were notable for a Cr of 2.3 mg/dL (baseline 2.1 mg/dL), platelets of 142,000/mm3, and a hemoglobin of 10g/dL. Telemetry noted consistent sinus rhythm. Initial electrocardiogram (ECG) revealed sinus rhythm, rate of 78 beats per minute, with a large prominent S wave in lead 1 along with a Q wave and an inverted T wave in lead III (Figure 1). D-dimer was elevated at 606 ng/ml (ULN 225 ng/ml). Given his renal dysfunction, a V/Q scan was ordered which detected a mismatch in the right upper lobe consistent with a pulmonary embolism (PE). Doppler ultrasound of his lower extremities was negative for any deep vein thrombosis. He was started on oral anticoagulation and discharged with a Holter monitor with plans to follow up with his primary care provider.