Author: Amber Mounday, MD
Co Author #1: Stephen Scharmann, MD
Senior Editor: Yaowen Hu, MD, MBA
Editor: Caitlyn Mooney, MD

Patient Presentation:
Palpitations and near-syncope while training and racing at high level.

History:
A 43 year-old female elite endurance athlete with no significant past medical history presents to the sports medicine clinic with the complaint of increasing palpitations. She also describes near-syncopal episodes at the start of a few high-profile races over the last several months. Palpitations have now become worse at rest, with light-headedness and shortness of breath during some episodes. She also endorses the development of intolerance of high intensity anaerobic training and the inability to get her heart rate to her predicted maximum. She denies any chest pain at rest or with activity. Her family history is positive for hypertension, coronary artery disease in her parents, and sudden cardiac death in two grandparents attributed to coronary artery disease at an advanced age.

Physical Exam:
Vital Signs: Temperature 37.3 degrees Celcius, Blood pressure :132/84, Pulse 50, Respiratory rate 12, Oxygen Saturation 98%
General: Well nourished, body mass index 20.
HEENT: No thyromegaly or goiter present.
Pulmonary: Lungs clear to auscultation.
Cardiac: Normal S1 and S2, no appreciable murmurs or ectopy at rest or with valsalva. Point of maximal impulse normal. Symmetric distal pulses.
Musculoskeletal: No peripheral edema.
Integumentary: No rashes, jaundice.
Neuro: No motor or sensory deficits. 5/5 strength in the upper and lower extremities. Deep tendon reflexes normal and brisk.
Psych: Normal affect. Appropriate behavior.

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