A Patient Who Collapsed in Agony After Echocardiography

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


May 19, 2022

Physical Examination and Workup

Upon initial presentation in the ED, the patient's heart rate is 56 beats/min, his blood pressure is 149/81 mm Hg, his respiration rate is 18 breaths/min, and his temperature is 98.5 °F (36.9 °C). His height is 67 in (170.2 cm), and his weight is 212 lb (96.2 kg). He is alert and oriented. His pupils are equal, round, and reactive to light. No erythema is noted in his mouth, and the mucous membranes appear moist. The patient can move all four extremities spontaneously. No rashes are visible; however, he appears pale and diaphoretic.

Lung fields are clear; no wheezing, rales, or rhonchi are audible. During auscultation of the heart, no murmurs, rubs, or gallops are noted. Radial pulses are equal and palpable. The patient has mild nonpitting bilateral lower extremity edema. His abdomen is soft and nontender to palpation. Bowel sounds are audible in all four quadrants. Costovertebral angle tenderness is noted on examination. The patient reports no tenderness on palpation of the lumbar region.

A stat one-view portable radiograph and an ECG are ordered. The only abnormal radiographic findings are slightly flattened diaphragmatic domes and large lung volumes. No cardiomegaly and no effusions or other signs of fluid overload are present.

The ECG demonstrates normal sinus rhythm at 62 beats/min. All intervals are within normal limits. No ischemic ST-segment changes are observed. Poor R-wave progression is noted; this finding suggests a previous anterior myocardial infarction. Evidence of left ventricular hypertrophy is present.

The results of repeated laboratory studies are within normal limits and reveal no elevations in troponin levels. His brain natriuretic peptide (BNP) level is 46 pg/mL (reference range, < 450 pg/mL). His leukocyte count is 10,105 cells/µL (reference range, 4000-11,000 cells/µL). His blood glucose level is 156 mg/dL (reference range, < 200 mg/dL [random measurement]), as he had not fasted.

The patient reports the complete resolution of his symptoms prior to the administration of diphenhydramine. He is given the medication and is observed in the ED for several hours before being sent home with strict follow-up instructions.


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