Author: Andrew Cox, MD
Co Author #1: Rachel Lampert, MD
Co Author #2: Robert Elder, MD
Co Author #3: Matthew Lynch, MD
Senior Editor: Rachel Coel, MD, PhD

Patient Presentation:
The patient is a 20 year old adopted female collegiate field hockey player with an otherwise unremarkable past medical history, taking a combined hormonal oral contraceptive pill, who presents with 3 episodes of near syncope with worsening substernal chest pain over a period of 6 months. Each episode occurred during strenuous exertion, which included combinations of aerobic conditioning (ie. shuttle runs) and Olympic lifting. Despite her associated headache, lightheadedness and dizziness, she never lost consciousness. The episodes varied in duration, lasting anywhere from 5 to 10 minutes during the initial incident to about an hour with the third incident. After the third episode, she underwent formal cardiology evaluation including an EKG and echocardiogram.

History:
Past Medical History: unremarkable
Past Surgical History: Left knee meniscal repair
Medications: combined oral contraceptive pill
Allergies: none
Family History: unknown, adopted
Social History: collegiate varsity athlete, sophomore. Sporadic alcohol intake, denies risky drinking, tobacco or illicit drug use.

Physical Exam:
Vitals: 115/78, HR 79, SPO2 99%, WT 54 kg, HT 5 feet, BMI 23.1
GEN: well appearing female, no acute distress
HEENT: moist mucous membranes, no oropharyngeal lesions, anicteric sclera, no conjunctival pallor
CV: S1 with physiologic split S2 with inspiration, no murmur, rubs or gallops, JVP 5cm H2O, no carotid bruits
Pulm: clear to auscultation in all lung fields
Abdomen: active bowel sounds, soft, non-tender, non-distended without evidence of organomegaly
Skin: no obvious skin lesions
MSK: No musculoskeletal deformities
Extremities: warm, well perfused, brisk capillary refill, 2+ peripheral pulses in bilateral upper and lower extremities. No clubbing, cyanosis or edema.

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