A 68-year-old man comes to the emergency department due to sev | Uworld | Step 2ck

A 68-year-old man comes to the emergency department due to severe dizziness while playing tennis an hour ago. He says that he had a spinning sensation accompanied by nausea and vomiting; the symptoms have now subsided. The patient has had brief episodes of dizziness in the past, especially when performing vigorous work with his arms. He has also experienced heaviness and fatigue of the left arm with exertion. The patient has a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus. Blood pressure is 140/90 mm Hg on the right arm and 100/74 mm Hg on the left, and pulse is 82/min and regular. A systolic bruit is present at the base of the neck just above the clavicle on the left side. Cardiac auscultation discloses a fourth heart sound. There is no extremity weakness or sensory loss.