Palpitations in a 19-Year-Old With a Rash

Jason S. Chang, MD; Carin M. Van Gelder, MD

Disclosures

May 14, 2015

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 you would like to suggest for a future Case Challenge, please contact us.

Background

A 19-year-old white male presents to the emergency department (ED) in Connecticut after an episode of shortness of breath and syncope while at home. He reports having experienced recurrent episodes of palpitations and fatigue in the week before presentation.

Yesterday, the patient sought medical attention for these symptoms at his pediatrician's office. An ECG was performed, but the findings were normal; the patient was sent home wearing a Holter monitor (also known as an "ambulatory ECG device").

Today, while mowing the lawn, the patient again felt a sudden onset of palpitations, accompanied by shortness of breath and light-headedness. He went inside the house, where he suddenly "passed out," according to the patient's girlfriend. The girlfriend also states that he was unresponsive for a couple of minutes and that the patient exhibited no seizure-like activity or incontinence. She noted that he was "pretty much himself" once he regained consciousness. He was then brought by ambulance to the ED; a rhythm strip was acquired en route (Figure 1). Prophylactic transcutaneous pacer pads were placed by the emergency medical services team.

In the ED, the patient describes his palpitations as irregular, forceful beats, with a sensation of a racing heart. They occur spontaneously, without any clear inciting factors. He denies having any chest pain or shortness of breath at the time of questioning in the ED. He has not experienced any similar events before these, and he is usually active and athletic.

The patient denies having any recent fever, upper respiratory infections, cough, or sore throat. He denies having any recent headaches, neck stiffness, tinnitus, vertigo, or focal neurologic deficits. He also denies experiencing any bleeding (eg, hematochezia or melena).

The patient has been eating a regular diet and has not had any recent weight loss. His medical history is significant only for a cervical spine fracture secondary to a diving accident that occurred 3 years ago. He has no residual deficits or physical limitations. The patient is otherwise healthy, with no known cardiac, neurologic, or pulmonary disease. He has no known family history of sudden death or premature cardiac disease. He does not take any regular medications, and he denies any drug abuse, tobacco use, or alcohol consumption.

The Holter monitor had been removed before the patient began to mow the lawn; therefore, no results were available to ED staff.

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