Author: Sanjay Dronavalli, MBBS
Co Author #1: Shilpa Junna, MD
Senior Editor: Drew Duerson, MD
Editor: Jennifer Gaitley, MD

Patient Presentation:
A 60-year-old male presented to the primary care clinic to establish care. He is an avid cyclist and bikes 5 days a week for approximately 3 hours at a good pace of between 16-20 miles per hour. He had cycled 20 plus miles to arrive at his primary care appointment on the day of presentation. During the appointment, he reported recent chest congestion and tightness while cycling which resolves a few hours after his ride. At the time of office appointment, he denied lightheadedness, dizziness, syncope, chest pain, shortness of breath, peripheral edema, or changes in mentation.

History:
He had a past medical history of neurosarcoidosis status post high dose steroid therapy, now weaned off of steroids. He also has a history of agoraphobia.
He does not take any current medications and denied over the counter supplement use. No family history of structural heart disease or heart block.

Physical Exam:
VITALS: Blood pressure 194/90 mmHg, heart rate 40 beats per minute, SpO2 98%. Temperature 36.6 degrees Celsius. GENERAL APPEARANCE: Alert and oriented times 4, generally well-appearing male, in no acute distress. Thin build. Head/Eyes/Ears/Nose/Throat: Normocephalic and atraumatic. HEART: Normal rate and regular rhythm, normal S1/S2, no murmurs, rubs, or gallops. LUNGS: clear to auscultation bilaterally, moving air well. No crackles or wheezes heard. ABDOMEN: Nondistended. EXTREMITIES: No cyanosis, clubbing or edema. NEUROLOGICAL: Grossly non-focal. Moving all 4 extremities. Cranial nerves not formally tested but appeared grossly intact. Observed to ambulate with normal gait. Skin: Warm and dry.

Click here to continue. Challenge yourself by writing down a broad differential diagnosis before moving to the next slide.