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Author Aarti Narayan MBBS, Raviteja Reddy Guddeti MBBS
Exam Type USMLE Step 3
Main Category Emergency Room
Sub Category Genitourinary, Cardiovascular, Genitourinary
Prompt A 60 yr old female with chronic kidney disease presented to the ER with symptoms of breathlessness, orthopnea, chest pain, and dizziness. On auscultation, heart sounds were faint. An EKG showed low voltage complexes. Blood pressure was 90/50 mm Hg. Lung fields were clear. What additional finding is expected on palpation of radial pulse?
Answer A Pulsus bisferiens
Answer A Explanation Pulsus bisferiens is a sign where on palpation of the pulse, a double peak in the aortic waveform is observed with each cardiac cycle. This finding is seen in hypertrophic cardiomyopathy.
Answer B Pulsus tardus
Answer B Explanation Pulsus tardus is the name of the delayed systolic peak seen in aortic stenosis.
Answer C Pulses bigeminus
Answer C Explanation Pulsus bigeminus is a cardiovascular phenomenon characterized by groups of two heartbeats close together followed by a longer pause. The second pulse is weaker than the first. It is caused by premature contractions, usually of the ventricles, after every other beat.
Answer D Pulsus paradoxus
Answer D Explanation Pulsus paradoxus is the correct answer.
Answer E Pulsus parvus et tardus
Answer E Explanation Pulsus parvus et tardus, more commonly known as a "slow-rising" or "anacrotic" pulse, is a sign where, upon palpation, the pulse is weak/small (parvus), and late (tardus) relative to contraction of the heart. This finding is seen in aortic stenosis.
Right Answer D
Explanation The correct answer is pulsus paradoxus (PP). The patient in this vignette is suffering from cardiac tamponade most likely secondary to uremic pericarditis. Tamponade is strongly suggested by the muffled hear sounds, low voltage EKG, dyspnea and chest pain. The hallmark of cardiac tamponade on physical exam is pulsus paradoxus. Pulsus paradoxus (PP), also called paradoxic or paradoxical pulse, is an exaggeration of the normal variation in the pulse and drop of systolic blood pressure during the inspiratory phase of respiration, in which the pulse becomes weaker as one inhales and stronger as one exhales. It is a sign that is indicative of several conditions including cardiac tamponade and lung diseases (e.g.asthma, COPD).

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