A 32-year-old paramedic comes to the office for a routine health maintenance examination. He has had headaches for the past several months as well as episodes of nosebleeds. He has no other medical problems. The patient does not use tobacco or illicit drugs but drinks 1 or 2 cans of beer daily. He has no family history of heart failure or sudden death.
Temperature is 36.1 C (97 F); blood pressure is 188/96 mm Hg in the right arm, 184/94 mm Hg in the left arm, and 114/76 mm Hg in the right leg; pulse is 68/min, and respirations are 14/min. Height is 180 cm (5 ft 11 in). Examination reveals no audible carotid bruits. There is a 2/6 mid-systolic murmur heard at the left sternal border as well as a continuous "rumbling" sound heard in the back over the interscapular area.
Diagnostic testing is most likely to demonstrate which of the following findings?

Question

A 32-year-old paramedic comes to the office for a routine health maintenance examination.  He has had headaches for the past several months as well as episodes of nosebleeds.  He has no other medical problems.  The patient does not use tobacco or illicit drugs but drinks 1 or 2 cans of beer daily.  He has no family history of heart failure or sudden death.
Temperature is 36.1 C (97 F); blood pressure is 188/96 mm Hg in the right arm, 184/94 mm Hg in the left arm, and 114/76 mm Hg in the right leg; pulse is 68/min, and respirations are 14/min.  Height is 180 cm (5 ft 11 in).  Examination reveals no audible carotid bruits.  There is a 2/6 mid-systolic murmur heard at the left sternal border as well as a continuous "rumbling" sound heard in the back over the interscapular area.
Diagnostic testing is most likely to demonstrate which of the following findings?

Quizplus · Accepted Answer

11ec193a_9737_b29c_853d_a5f3f9ada6ec_MD0002_00 This patient most likely has secondary hypertension due to coarctation of the aorta (CoA). A congenital narrowing of the descending aorta leads to proximal hypertension and decreased blood flow to the lower extremities. Asymptomatic hypertension of the upper body is the most common adult presentation, but patients can have headaches, epistaxis, lower extremity claudication, or symptoms of heart failure. On physical examination, brachial-femoral pulse delay strongly suggests the diagnosis. In addition, patients frequently have a continuous murmur, due to blood flow through collateral vessels (eg, intercostal arteries), that is best heard at the posterior interscapular area. narrowing of the descending aorta An accompanying systolic murmur in a patient with CoA is typically the result of a coexisting cardiac lesion. Congenital bicuspid aortic valve is the most common defect associated with CoA (in approximately 40% of cases) and can be identified by echocardiography. Other commonly associated defects include ventricular septal defect, patent ductus arteriosus, and subvalvular or supravalvular aortic stenosis. (Choice A) Atrial septal defect (primum type) is seen in patients with Down syndrome but is not associated with CoA. (Choice C) Pulmonic stenosis is seen in association with tetralogy of Fallot and congenital rubella syndrome but does not have a significant association with CoA. (Choice D) Right ventricular dysplasia is characterized by a combination of regional or global right ventricular abnormalities, characteristic fibrofatty changes on tissue biopsy, arrhythmias, and a family history of sudden death, but it is not associated with CoA. (Choice E) Wolff-Parkinson-White syndrome is seen in up to 20% of patients with Ebstein anomaly of the tricuspid valve; however, it is not associated with CoA. Educational objective: Coarctation of the aorta is a congenital narrowing of the descending aorta that causes upper body hypertension and may lead to lower body claudication. The condition may remain undiagnosed until adulthood. It is associated with several other congenital cardiac defects, with bicuspid aortic valve being the most common. __________ References: Bicuspid aortic valves in hearts with other congenital heart disease. (http://www.ncbi.nlm.nih.gov/pubmed/8611973) Risk factors for aortic complications in adults with coarctation of the aorta. (http://www.ncbi.nlm.nih.gov/pubmed/15489097)

A 32-Year-Old Paramedic Comes to the Office for a Routine