WBR0002

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Author Raviteja Reddy Guddeti (Edited by Will Gibson and Alison Leibowitz)
Exam Type USMLE Step 2 CK
Main Category Internal medicine
Sub Category Cardiovascular
Prompt A 68-year-old man presents to the Emergency Room after losing consciousness while climbing stairs. He denies any pre-syncopal symptoms, or any past history of neurologic conditions. However, the patient reports having experienced increasing shortness of breathe and chest pain on exertion over the past 3 years. Which carotid pulse pattern is most likely to be observed in this patient?
Answer A Pulsus bisferiens
Answer A Explanation [[AnswerAExp::Pulsus bisferiens is a pulse characterized by two strong systolic peaks separated by a midsystolic dip, most commonly occurring in pure aortic regurgitation with stenosis.]]
Answer B Pulsus paradoxus
Answer B Explanation [[AnswerBExp::Pulsus paradoxus is the hallmark of tamponade. It is defined as drop in systolic blood pressure by more than 10 mm Hg during inspiration. It is also seen in asthma and COPD.]]
Answer C Pulsus parvus et tardus
Answer C Explanation [[AnswerCExp::Pulsus parvus et tardus is a common feature of aortic stenosis. Typical findings in aortic stenosis include a narrow pulse pressure, left ventricular hypertrophy, a harsh systolic murmur with radiation to the carotid arteries, and a delayed slow-rising carotid upstroke (pulsus parvus et tardus).]]
Answer D Pulsus alternans
Answer D Explanation [[AnswerDExp::Pulsus alternans refers to a pulse showing alternating strong and weak beats. It is observed in congestive heart failure and its presence carries a poor prognosis.]]
Answer E Pulsus bigeminus
Answer E Explanation [[AnswerEExp::Pulsus bigeminus refers to a “bigeminal” pulse: a pulse characterized by two beats occur in rapid succession, the groups of two being separated by a longer interval. It is observed in hypertrophic cardiomyopathy (HCM).]]
Right Answer C
Explanation [[Explanation::The patient in this vignette most likely suffers from aortic stenosis. Aortic stenosis most commonly develops as an age related calcification of a three-leafed aortic valve in the elderly population (late 60s to 80s). Calcification leading to stenosis occurs earlier in patients withbicuspid valves, often in their 40s to 50s. Aortic stenosis causes pulsus parvus et tardus, a pulse which is weak/small (parvus), and late (tardus) relative to its expected character due to outflow obstruction at the aortic valve. The symptoms of aortic stenosis can be remembered with the mnemonic: SAD
  • Syncope
  • Angina
  • Dyspnea

Educational Objective: Aortic stenosis causes pulsus parvus et tardus, a pulse which is weak/small (parvus), and late (tardus) relative to its expected character due to outflow obstruction at the aortic valve.
References: video tutorial (2:08)]]

Approved Yes
Keyword Aortic stenosis, Waveform, Carotid waveform, Carotid pulse, Carotid, Pulse, Pulsus
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