Visual Diagnosis: Syncopal Episode in a 14-year-old Adolescent Boy

Andrea Younes, MD* 2. Ijeoma Ananaba Ekeruo, MD† 3. Monaliza S. Evangelista, MD‡ 1. *Department of Pediatrics, 2. †Division of Cardiology, Department of Internal Medicine, and 3. ‡Division of Community and General Pediatrics, Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX A 14-year-old Hispanic boy with a medical history significant for panic attacks and depression presents to the emergency department after a syncopal episode. He was in school at the time of the event, and the last thing he remembers before losing consciousness is that he was sitting on the edge of the school theater stage. The event was witnessed by his schoolmates, who alerted their teachers. He woke up spontaneously but appeared confused. Emergency medical services were notified, and he was taken to the emergency department. Before this episode, he had no history of headache or dizziness. He has had chest pain and palpitations previously, but he attributes these symptoms to the panic attacks. He was in his normal state of health and has never experienced a syncopal episode until this time. He does not engage in sports at school but is able to participate in regular physical activity without experiencing difficulty or limitation of activity. Of note, the boy has experienced several panic attacks over his lifetime, with the most recent being 1 year ago. He denies any associated syncopal events. His social history is significant for admission to a psychiatric hospital due to suicidal ideation several months before this presentation. Currently, he is taking fluoxetine and aripiprazole but does not use alcohol or other substances. The family history is normal. On evaluation in the emergency department, he is afebrile, with a heart rate of 99 beats/min, respiratory rate of 12 breaths/min, and blood pressure of 124/70 mm Hg. The initial evaluation shows normal electrolyte values and complete blood cell counts. In addition, his troponin level is 0.0 …