SHM Converge Scientific Abstract ePoster Gallery-The Importance of Physical Examination: A 44 Year Delayed Diagnosis

Pdf Summary

This case highlights the importance of a careful physical examination in diagnosing a condition that had been missed for 44 years. A 44-year-old man was admitted with dyspnea and cardiogenic shock due to rapid atrial fibrillation. He improved after inotropes and afterload reduction, with ejection fraction rising from 20% to 40–45%, and was transferred for further diuresis.<br /><br />His history included a bicuspid aortic valve and recently diagnosed atrial flutter, but he had limited access to healthcare and no primary care physician. On exam, clinicians noted a diastolic murmur, elevated JVP, mild edema, and unusually vigorous pulses. These findings raised suspicion for high-output heart failure and prompted further evaluation.<br /><br />Echocardiography showed bicuspid aortic valve disease with moderate aortic insufficiency, severe tricuspid regurgitation, and pulmonary hypertension. However, cardiac MRI revealed the true underlying problem: coarctation of the aorta with major collateral circulation, later confirmed by gated CT angiography. Rib notching on imaging supported the presence of long-standing collateral flow.<br /><br />The patient underwent atrial flutter ablation, was started on guideline-directed medical therapy, and was referred to cardiothoracic surgery for eventual repair of the coarctation. Two years after diagnosis, he was doing well and remained NYHA class I–II.<br /><br />The report emphasizes that physical signs such as Corrigan’s pulse and Quincke’s pulse, classically associated with severe aortic regurgitation, can also be seen in coarctation due to high proximal pressure and vigorous peripheral pulsations. Distal pulse reduction and radial-femoral delay are additional clues. This case is notable as the first reported instance of Quincke’s pulse in a patient with aortic coarctation. The key teaching point is that bedside physical exam remains crucial for hospitalists and can directly guide diagnosis and management.

Asset Subtitle

Ajay B. Mohinani

Meta Tag

Author List Ajay B. Mohinani, André M. Mansoor

Category Clinical Vignettes

Concept Aortic Insufficiency

Concept Coarctation of the Aorta

Concept Corrigan Pulse

Concept Radial-Femoral Delay

Concept Bedside Physical Exam

Distinguished Non-Finalist

Presenter Organization Oregon Health & Science University

Presenting Author Ajay B. Mohinani

Track Adult

Keywords

coarctation of the aorta

Quincke's pulse

Corrigan's pulse

bicuspid aortic valve

atrial flutter

heart failure

cardiogenic shock

aortic insufficiency

rib notching

physical examination

Aortic Insufficiency

Coarctation of the Aorta

Corrigan Pulse

Radial-Femoral Delay

Bedside Physical Exam