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In this EM:RAP Case of the Month, Jan and Swami kick off Groundhog Day by diving into a deceptively common ED presentation: cough and syncope. A 46-year-old woman with URI symptoms and post-tussive syncopal episodes prompts a thoughtful walk-through of syncope risk stratification, differential diagnosis, and standard workup, until an unexpected chest x-ray reveals a massive hiatal hernia. What follows is a fascinating diagnostic pivot, highlighting a rare but high-stakes cause of syncope due to extrinsic cardiac compression, confirmed on CT and echo and ultimately requiring urgent surgical repair. This case is a powerful reminder to stay curious, respect the basics, and recognize when an “incidental” finding can dramatically change management. ✔ Subscribe today: https://www.emrap.org/subscribe ✔ Newsletter sign up: https://www.emrap.org/newsletter ✔ Donate to our non-profit, EM:RAP Global Outreach: https://www.emrapgo.org/ EM:RAP on Social Media: ► Follow on Twitter: / emrap_tweets ► Like on Facebook: / emergencymedicine ► Follow on Instagram: https://www.instagram.com/emrapshow/?... ► Subscribe on YouTube: / emrapmedical Visit https://www.emrap.org/ for all your Emergency Medicine education! #emrap #emergencymedicine #urgentcare #meded