An 18-Year-Old Woman Who Fainted and Can’t Remember

Editor's 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. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

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. The patient also recalls that her younger brother has had similar episodes of syncope over the past few years.

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.

Physical Examination and Workup

Upon examination, the patient is relaxing comfortably, without any undue signs of distress or anxiety. She meets your gaze and rises from her bed to shake your hand when you meet.

The physical examination reveals that she has a temperature of 98.4° F (36.9° C), with a heart rate of 65 beats/min and a blood pressure of 110/73 mm Hg. Head and neck examination findings are unremarkable. She has normal S1 and S2 heart sounds, without any appreciated rubs, murmurs, or gallops. She has no jugular venous distention, and her lungs are clear bilaterally. Her abdomen is soft, nontender, and without masses. Normal bowel sounds are present. She has no peripheral edema, and the findings of the neurologic examination are normal.

The results of her laboratory workup, including a complete blood count (CBC), chemistry panel, pregnancy test, and toxicology screen, are normal. A chest radiograph is taken (not shown) that is likewise normal. An electrocardiogram (ECG) is obtained (Figure 1). Note: The ECG recording was performed using a 25 mm/sec paper speed.

(Enlarge Image)

Figure 1.

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