<prompt> A 68-year old man who has had a recent syncopal Episode is hospitalized with congestive hea failure failure. His blood pressure is 16080 mm Hg. His pulse rate is 80 Beats minute,and there is agrade llllV harsh systolic murmur.Radiation of the murmur to die neck.Decrease of me murmur with handgripDelayed carotid upstrokeReduced left ventricular ejection fraction  <response>: Carotid upstroke. A delayed upstroke pulsus parvus et tardus can suggest aoic stenosis, left ventricular outflow obstruction, or significant decrease in stroke volume. Vascular stiffness due to aging can reduce the delay, causing a more normal-feeling upstroke Ref Davidson 23rd edition pg 456 