Robbie

And you said he was hypertensive afterwards, which I think is just probably more autonomic than anything else in his body trying to recover.

So if I, you know, going back to the original differential diagnosis, which of those two, ACS or PE, I'm also tracking the possibility he might have something in his brain, Prof. Rez, but if he has ACS or PE, which one is more likely to present with syncope?

It's definitely a pulmonary embolism, though there are instances where ACS can present with syncope, but it would require a second-order mechanism, like it would require ACS-induced VT or ACS-induced... ACS purely presents...

with a continuous syndrome that gets worse and worse and worse and worse rather than PE, which has some cool mechanisms that can present with a syncopal event.

Beautiful.

Curious what the x-ray will show.

Okay.

Wow, this is very, very different.

Crazy x-ray progress.

So, you know, the major abnormality in this x-ray that I see is that his mediastinum looks really, really odd and really enlarged.

So I'm trying to make sure I'm not missing a pneumothorax.

I don't see that.

I don't see any pleural disease.

But he has very impressive widening of the mediastinum.

So this is very, very alarming.

I think the tube of truth of the CT is definitely the right thing to do.

What this could mean in terms of the original hypothesis, I think aortic dissection definitely wasn't on my mind as a presentation of exertional lightheadedness.

The way prompted by this x-ray and the benefit of not having to rush to diagnose this patient and manage this patient, the way that aortic dissection might be implicated in a transient loss of consciousness event is really, really interesting.

And essentially...

It has to do with focal cerebral hypoperfusion as the dissection extends into the cervical vessels.