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JAMA Cardiology Clinical Challenge
April 21, 2021

A Young Patient With Hives and Chest Pain

Author Affiliations
  • 1Division of Emergency Medicine, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
  • 2Children’s Emergency Department, KK Women’s and Children’s Hospital PTE Ltd, Singapore
  • 3Division of Emergency Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 4University Health Network, University of Toronto, Toronto, Ontario, Canada
JAMA Cardiol. 2021;6(7):847-848. doi:10.1001/jamacardio.2021.0749

A patient in their 20s presented to the emergency department with presyncope, hives, and nausea after walking outside in the cold. On arrival, their pulse was 120 beats per minute; blood pressure, 85/52 mm Hg; respiratory rate, 20 breaths per minute; oxygen saturation, 100% with a nonrebreather mask; and temperature, 36.8° C. The patient was in moderate respiratory distress, and chest auscultation revealed bilateral wheezing. They were treated for presumed anaphylaxis with 0.5 mg of epinephrine intramuscularly. Immediately after the administration of epinephrine, they developed a headache, nausea, and chest pain. A 12-lead electrocardiogram (ECG) was obtained 5 minutes later (Figure 1). The patient had persistent hypotension.

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