A Patient Who Collapsed in Agony After Echocardiography

Catherine Divingian, MD, PhD; Valerie Gironda, MD; Francisco Torano, MD; Jeffrey Jordan, MD


May 19, 2022

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.


A 59-year-old man is rushed to the emergency department (ED) after he experienced intense, sudden-onset pain, particularly on the right side of his flank and lumbar region. Initially, the patient had presented to his primary care physician with orthopnea, dyspnea on exertion, and an increase in peripheral edema over the past few weeks. Laboratory test results were within normal limits, with the exception of these elevated values:

  • Fasting glucose level: 127 mg/dL (reference range, 70-99 mg/dL)

  • Leukocyte count: 11,520 cells/µL (reference range, 4000-11,000 cells/µL)

  • Low-density lipoprotein cholesterol level: 126 mg/dL (reference range, < 100 mg/dL)

  • Triglyceride level: 162 mg/dL (reference range, < 150 mg/dL)

He was referred to a cardiologist and had just completed an echocardiogram that morning as part of the workup before he collapsed in the hallway.

The patient has a past medical history of coronary artery disease, hypertension, and hyperlipidemia. He underwent emergent coronary angiography 5 years earlier and had two stents placed in the diagonal arteries. His current medications include metoprolol tartrate, atorvastatin, aspirin, and amlodipine. He states that he takes his medications and regularly follows up with his primary care physician.

The patient smoked cigarettes for more than 35 years, starting at age 18 years, but quit nearly 7 years ago. He does not drink alcohol or use illicit drugs.


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