Interesting Cases

Fainting in a 24 year old male

Near-Syncope in a 24-Year-Old Man

Background

 

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A 24-year-old man with no significant past medical history presents to the emergency department (ED) with a complaint of several episodes of a sensation of nearly blacking out. The episodes have occurred about 3-4 times over the 3 days before presentation. The duration of each episode has ranged from a few minutes to over an hour. The patient notes that he has felt his "heart beating really fast," with associated light-headedness. He denies having any chest pain, shortness of breath, or nausea associated with these events. He cannot identify exacerbating or alleviating factors; specifically, he denies exertion as an inciting factor. The remainder of his review of systems is negative except for some mild chronic shortness of breath. The patient takes no medications at home and has no active medical conditions. He smokes 2-4 packs of cigarettes per day and has done so for 5-6 years. He denies any illicit drug use or recent use of over-the-counter medications or herbal remedies. He has no history of any significant cardiac disease or sudden cardiac death in his family.

On physical examination, the patient is afebrile, with a pulse of 65 bpm, a blood pressure of 120/84 mm Hg, and a respiratory rate of 15 breaths/min. His room air saturation reading is 100%. In general, he is well-appearing and in no acute distress. The patient's neck examination shows no jugular venous distention. The heart sounds, including S1and S2, reveal no audible murmurs, rubs, or gallops. The apical impulse is nondisplaced and of normal impact. The lung sounds are diminished throughout, but there are no wheezes, rales, or rhonchi. He has no edema of the lower extremities, and the distal pulses are easily palpable. All other exam findings, including a neurologic examination, are unremarkable.

The patient is placed on a cardiac monitor, and an 18-gauge intravenous (IV) catheter is inserted into the antecubital fossa. Laboratory tests consisting of a complete blood count (CBC) and serum electrolytes are ordered. A portable chest radiograph reveals slight hyperinflation and hyperlucency of the lung fields, with a flattened diaphragm and central pulmonary artery enlargement. An electrocardiogram (ECG) is obtained (see Figure 1).

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Bird Droppings and a Chronic Cough

A 46-year-old man presents to the emergency department (ED) with a 4-day history of dry cough, fever, chills, night sweats, a 13-lb (5.9-kg) weight loss, (over a 2-week period), shortness of breath, and easy fatigability. Two weeks before presentation, he went with a friend to clean an abandoned house in Kentucky. The house was very dusty and had a lot of bird droppings. His friend developed a fever with cough and could not continue working after 4 days. Our patient, however, continued to work until the job was done (a total of 7 days). He has not had any hemoptysis, chest pain, or any other symptoms, except as noted above. He has mild asthma, uses an albuterol inhaler once every 3-4 months, has smoked half of a pack of cigarettes per day for the last 30 years, does not drink alcohol, and does not use any illicit drugs. He has no significant family history and is not allergic to any medications.

On physical examination, his oral temperature is 98.9°F (37.2°C). His pulse is regular, with a rate of 98 bpm, and his blood pressure is 137/91 mm Hg. He is mildly tachypneic, with a respiratory rate of 22 breaths/min. The patient is thin but not emaciated, and he has poor dentition; his head and neck examination is otherwise normal, with no palpable lymph nodes. He has normal S1 and S2 heart sounds. Chest auscultation reveals fine rales in the mid and lower zones of both lungs. His abdomen is soft and nontender, with normal bowel sounds. He does not have any lower limb edema, and he has normal peripheral pulses.

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A Young Baseball Player in Cardiac Arrest

Background
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A paramedic call is received in the emergency department (ED) reporting a 10-min estimated time of arrival for a 17-year-old male who was found in cardiac arrest following a blow to the chest. The patient has regained spontaneous circulation, and is currently stable and maintaining his own airway. A rhythm strip faxed to the ED prior to the patient's arrival shows ventricular fibrillation, with subsequent conversion to a normal sinus rhythm after defibrillation with 200 joules (see Figure 1). Further questioning of the prehospital personnel reveals a history of witnesses reporting that the patient, a center outfielder for a local baseball team, was trying to catch a baseball when one of his teammates accidentally ran into him, elbowing him in the middle of his chest. The patient immediately dropped to the ground and was unresponsive. Cardiopulmonary resuscitation (CPR) was initiated by his coach after no pulses were palpated. The paramedics arrived 5 minutes later and, as noted on the rhythm strip, found the patient to be in ventricular fibrillation. One 200 joule countershock was administered, converting the ventricular fibrillation to a normal sinus rhythm, and the patient was noted to regain consciousness.

Upon arrival at the ED, the patient reports only mild anterior chest wall pain and denies any substernal chest pain, shortness of breath, palpitations, weakness, or confusion. He states that he has never before fainted. The patient and his mother deny any significant past medical or family history, including any arrhythmias, unexplained sudden deaths, or cardiac structural diseases. He denies having a lower exercise tolerance than his teammates and also denies any smoking, drinking, use of medications, illicit substance abuse, or doping practices.

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