A 78-Year-Old Man Is Brought to the Emergency Department After

question 89

Multiple Choice

A 78-year-old man is brought to the emergency department after experiencing 2 episodes of syncope.  The first episode occurred yesterday while he sat reading a magazine after a heavy dinner.  The second happened today in the bathroom after urination.  The patient felt lightheaded and nauseated and had to sit down on the toilet seat before he briefly lost consciousness.  He has never had similar episodes before, but he has experienced some lightheadedness during brisk uphill walking.
Over the last several days, the patient has had lower abdominal cramps accompanied by 2 episodes of diarrhea.  He was diagnosed with aortic stenosis a year ago after a physical examination showed a murmur, but he refused to see a cardiologist for further evaluation.  In the emergency department, he says that he feels "weak but okay."
His blood pressure is 124/60 mm Hg.  Jugular venous pressure is estimated at 10 cm H₂O.  There is a harsh 4/6 systolic mid-peaking murmur at the base of the heart that radiates to both carotids.  The second heart sound is soft, and the carotid upstrokes are delayed after the first heart sound.  His lungs are clear on auscultation.  There is no peripheral edema.
An electrocardiogram is obtained in the emergency department.
Which of the following is the most likely cause of this patient's symptoms?

• A)Conduction system disease
• B)Left main coronary artery stenosis
• C)Severe narrowing of the aortic valve
• D)Vasovagal syncope
• E)Volume depletion

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