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Difficulty: HardPhysical Examination Findings

During a routine preoperative evaluation for an elective total knee arthroplasty, an asymptomatic 79-year-old woman is noted to have a prominent cardiac murmur. She denies any recent syncope, angina, or dyspnea, although she admits her activity level is minimal due to severe osteoarthritis. Vital signs show a blood pressure of 124/76 mmHg and a regular pulse of 68/min. Cardiac auscultation at the right second intercostal space reveals a loud crescendo-decrescendo systolic ejection murmur that radiates to the carotid arteries. The anesthesiologist requests a cardiology consultation to determine if the valvular lesion is hemodynamically significant, which would increase her perioperative risk.

Which TWO of the following concurrent physical examination findings would most strongly indicate that this patient's aortic stenosis is hemodynamically severe? (Select exactly two options)

  1. Pulsus parvus et tardus (diminished and delayed carotid upstroke)Answer
  2. B
    Early-peaking crescendo-decrescendo murmur
  3. Soft, single second heart sound (S2)Answer
  4. D
    Brisk, bifid carotid upstroke (pulsus bisferiens)
  5. E
    Widely and fixed split second heart sound (S2)

Answer

The physical examination findings most indicative of severe aortic stenosis are a diminished and delayed carotid upstroke (pulsus parvus et tardus) and a soft, single second heart sound (S2).
In hemodynamically severe aortic stenosis, the heavily calcified and narrowed aortic valve fundamentally alters left ventricular outflow. Because it takes longer for the left ventricle to eject blood through the tight orifice, the carotid upstroke becomes notably weak and delayed (pulsus parvus et tardus). Furthermore, the rigid, immobile aortic leaflets fail to snap shut properly, leading to a diminished or completely absent aortic component (A2) of the second heart sound. This results in a soft, single S2, or occasionally paradoxical splitting.

Step-by-Step Solution

1
Analyze the clinical vignette and identify the primary structural lesion.
The patient has a loud crescendo-decrescendo systolic murmur at the right upper sternal border radiating to the carotids, which is classic for aortic stenosis.
Establishing the baseline valvular abnormality is required before assessing its severity.
2
Differentiate the physical examination findings of mild-to-moderate versus severe aortic stenosis.
Severe aortic stenosis presents with a late-peaking murmur, pulsus parvus et tardus, and a soft/single S2. Mild disease presents with an early-peaking murmur and a normally split S2.
The question specifically asks for markers of hemodynamically severe disease.
3
Evaluate the given options against the classic signs of severe aortic stenosis.
The options describing pulsus parvus et tardus and a soft, single S2 correctly identify severe disease. The other options describe mild disease or entirely different pathologies.
Systematic elimination ensures the selection of the precise constellation of findings for the requested severity.

Key Concept

The classic physical examination findings of hemodynamically severe aortic stenosis include pulsus parvus et tardus (delayed, weak carotid upstroke), a late-peaking systolic murmur, and a soft, single second heart sound (S2) due to immobility of the calcified leaflets.
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Physical Examination Findings

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