Q. A 75-year-old man comes to the emergency department due to transient loss of consciousness (syncope). The syncopal attack occurred while he was trying to shovel the ice in his backyard. The patient was born and in the United States and has never traveled abroad. He used to work as a clerk in a large tech company in California; however, he is now retired. He has no significant medical history except for some mild hypertension and osteoarthritis. On review of systems, he does comment that intermittently throughout his life he will experience a fluttering feeling and his pulse will feel irregular, but it doesn't last, so he's never thought anything of it. The patient's vital signs are normal except for irregular tachycardia. His cardiac auscultation reveals an additional late diastolic heart sound. ECG is performed, which demonstrates an irregular pattern and an absence of P-waves. On cardiac auscultation, you hear a sound that suggests the patient may have aortic stenosis in addition to his atrial fibrillation. Which of the following would have triggered this concern?