CARLOS EDUARDO REIS
A 62-year-old woman was admitted after a syncopal episode at home while walking in the garden. An ambulance brings her to the emergency room. Upon arrival at the hospital the woman was alert, slightly anxious, but in no acute distress, complaining only of pain in her left knee, which she apparently injured in the fall. She was placed on a cardiac monitor and blood was drawn for laboratory analysis.
Further history revealed that the fall was not preceded by an aura and the patient remained continent during the episode. She awoke about 1 minute later spontaneously complaining of pain in her left knee. The patient's past medical history is significant because of several episodes of light-headedness during exertion but never lost consciousness during those episodes and because of sporadic bouts of angina, for which she takes sublingual nitroglycerin. The angina has not recently increase in frequency or intensity, but the day prior to her syncopal episode she experienced mild angina that was relived by a sublingual nitroglycerin tablet. She had no previous history of diabetes, cerebral vascular accident or elevated cholesterol. She had smoked one pack of cigarettes daily for 15 years but had stopped smoking 10 years ago and uses no alcohol or drugs. The patient knows she had a heart murmur for many years but physician told her that it is not significant. Her father died in a car carsh at age 68, and her mother died for a heart attack at age 65
Physical examination revealed a well-developed, overweight white womam. Her skin were moist and vital signs were BP 110/70; pulse 94/min. and regular; temp. 100 degrees F, respirations of 12/min . Pupils were equal in size, round and reactive to light. Her extremities showed no cyanosis or edema.
Cardiac examination revealed a regular heart rhythm, with a normal first heart sound (S1), a soft second heart sound (S2), and a fourth heart sound (S4). She had a harsh crescendo-diminuendo, medium-pitched systolic murmur at right upper sternum, transmitted to carotids arteries and a systolic thrill at base. Her carotids demonstrated a delayed upstroke and low volume. Lung exam revealed no adventicious sound. Abdomen was soft, nontender, without masses or guarding. Neurologic examination was unremarkable.