You are incorrect - the most likely diagnosis in our patient is valvular aortic stenosis.


Your choice: Hypertrophic cardiomyopathy with subvalvular obstruction

Hypertrophic cardiomyopathy with subvalvular obstruction may present with distinct bedside findings.

These include a rapidly rising bifid arterial pulse, and a triple apical impulse with a presystolic and 2 systolic components. Two murmurs are heard: one at the mid-left sternal edge due to the subvalvular location of the obstruction, and the other at the apex, due to mitral regurgitation.

There is no ejection sound, as the aortic valve is not involved.