An 18-Year-Old Woman With Exercise-Induced Syncope

Lars Grimm, MD, MHS; Malkeet Gupta, MS, MD; Rick G. Kulkarni, MD


September 12, 2014

Editorial Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions.


An 18-year-old woman presents to the emergency department (ED) after experiencing a syncopal episode while backpacking two days ago. The patient states that she had been hiking with her friends up a steep hill, and the next thing that she remembered was waking up, lying on the trail. The event was not witnessed by any of her friends, and the patient does not recall any antecedent chest pain, shortness of breath, palpitations, or dizziness. She denies biting her tongue or having incontinence at the time of the event, but she remembers feeling briefly dazed. This feeling resolved quickly without any intervention. After a period of rest, she was able to finish the hike without further problems. Just to be safe, she has come to the ED to get checked out because she could not get an appointment to see her primary care provider. She denies any past medical problems, but she does report experiencing a similar syncopal episode a few years ago that also occurred while she had been exerting herself. At that time, she had dismissed the episode as nothing important because she had skipped breakfast that morning. She has no recent history of illness or fever and does not report any chest pains, shortness of breath, or palpitations subsequent to the event. She also denies any recent dieting or use of any over-the-counter or illicit drugs. Her menses have been normal and she takes a multivitamin every day. She is not currently taking any medications and denies having any allergies. She is a high school senior and lives at home in a safe environment with her family. She is looking forward to starting college in the fall. She denies knowledge of any cardiac or neurologic problems in her family.


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