Classic Aortic stenosis - Gallavardin phenomenon

65 year old male patient presented to our OPD with history of 

1- Shortness of breath on exertion .

2- bilateral pedal edema .

He was apparently assymptomatic 3 years back ,when he developed shortness of breath on exertion with bilateral pedal edema ,he approached a cardiologist and was diagnosed with heart problem .since then he is on medications and intermittently his Symptoms aggravate.

On examination - 

Patient is thin built.

Bilateral pedal edema - grade 2- extending upto knee ,pitting type .

PR- pulse was very feeble and slow rising regular . 

Carotid pulsations - slow rising ,low volume ( PULSUS PATVUS ET TARDUS) 

BP-100/60 mmHg 

 No raised JVP .

Cardiovascular system : 

Inspection - 

No precordial bulge .

Apex impulse is  visible below nipple .

Palpation - 

Apex impulse at 5th intercostal space and diffuse ,at midclavicular line .

No parasternal heave 

Auscultation - 

Mitral area-  loud ,high pitch systolic murmur was heard ,non radiating .

 Grade 3 systolic murmur .

Aortic area- Ejection systolic murmur -Classic Crescendo decrescendo murmur was heard that radiated to carotids and mitral area .

Murmur was heard clearly and loud at apex than aortic area ( GALLAVARDIN PHENOMENON ) .

Grade 3 systolic murmur .

Provisional diagnosis - Aortic stenosis .