![]() If we approach the differential diagnosis from the perspective of disease types that cause syncope (Table 1 ), we can hone in on the pertinent features of the case. Perhaps most important, these episodes tended to occur when she was in an upright position and while walking, so it was a positional syncope. She not only had four overt syncopal episodes but experienced multiple episodes of dizziness as well. There are a variety of ways to approach this case of a young woman, previously in good health, who presents with a 6-month history of fatigue, shortness of breath, and then more specific symptomatology, namely episodes of syncope. The patient was admitted to the hospital and underwent diagnostic procedures. The chest radiograph showed normal heart size and pulmonary vasculature with no infiltrates. Neurological examination was completely normal. External was warm no skin rash, splinter hemorrhages, clubbing, or cyanosis was found. The abdomen was soft, with no organomegaly and with normal bowel sounds. ![]() A grade 1 systolic murmur was intermittently heard at the apex position. A late diastolic sound was heard at the apex position. ![]() A prominent first heart sound was heard throughout the precordium. The heart rate was normal with a regular rhythm. Normal bronchovesicular breath sounds were heard throughout the lung fields. The neck showed no jugular venous distension and showed normal carotid upstrokes without bruits or murmur. HEENT was normal except for right fundi with a small pale lesion at the 10 o’clock position. The patient was a well-developed woman who appeared to be her stated age. Vital signs were: temperature, 99.0° (oral) blood pressure, 118/78 mm Hg pulse, 78 (no orthostatis changes) and respiratory rate, 16 per minute (unlabored). Her father and paternal aunt suffered myocardial infarctions in their fifties, and a brother died secondary to a myocardial infarction at the age of 37 years. There was a report of a strong family history of coronary artery disease. There was no medical history of seizure disorder, diabetes, or hypertension. There was no history of fever, illicit drugs, alcohol, receipt of blood products, recent travel, or exposure to toxic chemicals. There was a history of smoking for approximately 10 years, averaging a pack of cigarettes per day. She reported having symptoms of dizziness and near syncope frequently while driving the bus. The patient is employed as a school bus driver. Her syncope was always preceded by substernal chest pressure, dizziness, and breathlessness. Each of these episodes occurred as she proceeded to stand and walk from a sitting or lying position. The three syncopal episodes that followed the first occurred approximately 1 month apart. Her chest discomfort occurred at rest and with exertion. It was usually associated with dizziness and breathlessness but never with nausea, vomiting, or diaphoresis. Her chest discomfort was described as a squeezing sensation that was substernal in location without radiation to any other position. Her dizzy spells, which initially occurred weekly, became more frequent such that they occurred daily during the month before her hospital admission. She reported having dizzy spells that were initially associated with chest tightness and mild breathlessness. She did not initially seek medical attention for her fatigue and syncope. At that time, she sensed the onset of chest tightness and dizziness before losing consciousness. The first episode occurred as she proceeded to walk after a long period of standing. Approximately 4 months before her hospital admission, she had the first of four syncopal episodes. She reported having an increased amount of breathlessness when climbing the flight of stairs to her second-floor apartment. Her fatigue initially consisted of effort intolerance. The patient was in her normal state of health until approximately 6 months before admission, when she began suffering mild fatigue. Customer Service and Ordering InformationĪ 37-year-old woman was referred to Hermann Hospital from a local health maintenance organization clinic for the evaluation of fatigue, chest pain, and syncope.Stroke: Vascular and Interventional Neurology.Journal of the American Heart Association (JAHA).Circ: Cardiovascular Quality & Outcomes.Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB).
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