Case #1

A 65-year-old gentleman presents to the emergency room because of dyspnea and a severe headache. He has a history of hypertension and COPD for fifteen years for which he has been medically treated.

The patient appears to be in moderate to severe distress, is 5 10 tall and weighed 310 pounds. His blood pressure is 190/125 mmHg with a large cuff and his pulse is 60/minute. His pupils are equally reactive to light and accommodation. There is a right carotid bruit. On cardiac exam there is a prominent PMI with an S1, S2, S3 and S4. There are bibasilar rales ~2/3rd way up both lung fields. The abdomen is without masses or tenderness to palpation. The lower extremities are remarkable for diminished pulses and 3+ pitting edema.

Figure 1 Electrocardiogram