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