A 67-year-old man comes to the emergency department after losing consciousness while shoveling snow near his house. He reports having had a similar episode a month ago while carrying heavy bags from the grocery store. The patient has reduced his physical activity level over the last year due to progressive exertional dyspnea and fatigue. He has had no chest pain, palpitations, cough, or lower extremity swelling. His other medical problems include type 2 diabetes mellitus and hypercholesterolemia. He is a lifetime nonsmoker. Which of the following physical examination findings is most likely in this patient?

Question

A 67-year-old man comes to the emergency department after losing consciousness while shoveling snow near his house.  He reports having had a similar episode a month ago while carrying heavy bags from the grocery store.  The patient has reduced his physical activity level over the last year due to progressive exertional dyspnea and fatigue.  He has had no chest pain, palpitations, cough, or lower extremity swelling.  His other medical problems include type 2 diabetes mellitus and hypercholesterolemia.  He is a lifetime nonsmoker.  Which of the following physical examination findings is most likely in this patient?

Quizplus · Accepted Answer

Syncope has a broad differential diagnosis, from benign to life-threatening conditions. Exertional syncope usually portends an underlying pathologic cause, including ventricular arrhythmias (due to myocardial ischemia/infarction) and outflow tract obstruction (eg, aortic stenosis [AS], hypertrophic cardiomyopathy). The clinical presentation of progressive dyspnea on exertion, fatigue, and exertional syncope is suggestive of outflow obstruction. Patients with fixed outflow obstruction (eg, severe AS) cannot increase cardiac output in response to exercise-induced vasodilation, leading to hypotension, transient cerebral hypoperfusion, and decreased exercise tolerance, presyncope, or syncope. Physical examination findings suggestive of severe AS include: Delayed (slow-rising) and diminished (weak) carotid pulse ("pulsus parvus and tardus")Presence of single and soft second heart sound (S2)Mid- to late-peaking systolic murmur with maximal intensity at the second right intercostal space radiating to the carotids Delayed (slow-rising) and diminished (weak) carotid pulse ("pulsus parvus and tardus") Presence of single and soft second heart sound (S2) Mid- to late-peaking systolic murmur with maximal intensity at the second right intercostal space radiating to the carotids (Choice A) Blood pressure differential between the upper and lower extremities is seen with aortic coarctation, which can present with hypertension, headaches, blurred vision, epistaxis, and lower extremity claudication (due to reduced blood flow). A continuous murmur can be heard at the left interscapular area due to turbulent flow across the coarctation or through large collateral vessels. (Choice B) An opening snap and a late diastolic murmur best heard at the apex are characteristic of mitral stenosis, which can present with decreased exercise tolerance, exertional dyspnea, and, less commonly, chest pain, hemoptysis, or lower extremity edema. Exertional syncope is not seen. (Choice C) Prominent capillary pulsations in the fingertips or nail beds can be seen with aortic regurgitation (AR) as a result of widened pulse pressure. AR can present with progressive dyspnea and fatigue but is unlikely to cause exertional syncope. (Choice D) Pulsus paradoxus refers to an exaggerated decrease (>10 mm Hg) in systolic blood pressure (SBP) with inspiration. It is commonly seen with pericardial diseases (eg, cardiac tamponade) and can occur with severe asthma and chronic obstructive pulmonary disease. (Choice E) Orthostatic (postural) hypotension refers to a drop in SBP >20 mm Hg or diastolic blood pressure >10 mm Hg within 2-5 minutes of standing from a supine position. It does not cause exertional syncope. Educational objective: Aortic stenosis can present with decreased exercise tolerance, exertional dyspnea, angina, or syncope. Physical examination typically reveals a delayed and diminished carotid pulse, soft second heart sound, and mid- to late-peaking systolic murmur with maximal intensity at the second right intercostal space and radiation to the carotids.

A 67-Year-Old Man Comes to the Emergency Department After Losing