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Difficulty: EasyPhysical Examination Findings

A 75-year-old man presents to the outpatient clinic reporting a 3-month history of progressive exertional shortness of breath and occasional lightheadedness when climbing stairs. His vital signs are within normal limits. On physical examination, palpation of the carotid arteries reveals a pulse with a decreased amplitude and a delayed upstroke. Cardiac auscultation reveals a harsh, crescendo-decrescendo systolic murmur heard best at the right second intercostal space with radiation to the carotid arteries. Based on these physical examination findings, which of the following is the most likely diagnosis?

  1. Aortic stenosisAnswer
  2. B
    Aortic regurgitation
  3. C
    Mitral regurgitation
  4. D
    Mitral stenosis
  5. E
    Tricuspid regurgitation

Answer

Aortic stenosis
The correct diagnosis is Aortic stenosis. The physical examination findings presented are textbook hallmarks of this valvular disease. The delayed and weakened carotid pulse ('pulsus parvus et tardus') occurs because the narrowed aortic valve restricts left ventricular outflow, resulting in a slow rise in systemic arterial pressure. Furthermore, the harsh, crescendo-decrescendo systolic murmur heard at the right second intercostal space with radiation to the carotid arteries is the characteristic auscultatory finding of blood being forced through a stenotic aortic valve. These findings directly explain the patient's exertional symptoms.

Step-by-Step Solution

1
Analyze the characteristics of the patient's arterial pulse.
The carotid pulse exhibits a decreased amplitude and a delayed upstroke, classically known as pulsus parvus et tardus.
Identifying the specific pulse contour helps differentiate among left-sided valvular and vascular pathologies.
2
Evaluate the cardiac auscultation findings.
There is a harsh, crescendo-decrescendo systolic murmur located at the right second intercostal space that radiates to the carotids.
The timing (systolic), shape (crescendo-decrescendo), location, and radiation pattern of a murmur are key to localizing the structural defect.
3
Synthesize the physical examination findings to establish a diagnosis.
The combination of pulsus parvus et tardus and a classic aortic ejection murmur firmly points to severe narrowing of the aortic valve.
Matching isolated physical signs to form a cohesive clinical syndrome ensures diagnostic accuracy.

Key Concept

Physical examination hallmarks of Aortic Stenosis
Estimated Time:45s
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Physical Examination Findings

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