A 6-year-old boy is brought to the office by his mother for an annual physical examination. He has had no recent illnesses but has had intermittent pain in his legs during his soccer games for the past 3 months. The patient had no trauma preceding the onset of leg pain, has no numbness or tingling, and is able to walk without a limp. He was born at 38 weeks gestation via a spontaneous vaginal delivery with no complications. The patient has met all developmental milestones, and all of his immunizations are up to date. His father was recently diagnosed with hypertension at age 55, but there is no other significant family history. Temperature is 36.1 C (97 F), blood pressure is 135/88 mm Hg in the right upper extremity, pulse is 110/min, respirations are 24/min, and pulse oximetry is 98% on room air. Weight and height are at the 25th and 50th percentiles, respectively, for age. Physical examination shows a well-appearing boy who has no dysmorphic features and who smiles and fully cooperates. The lungs are clear to auscultation. Heart rate and rhythm are normal. A 2/6 continuous murmur is heard over the left interscapular area. The lower extremities have no swelling, erythema, or tenderness. Further evaluation would most likely show which of the following findings?

Question

A 6-year-old boy is brought to the office by his mother for an annual physical examination.  He has had no recent illnesses but has had intermittent pain in his legs during his soccer games for the past 3 months.  The patient had no trauma preceding the onset of leg pain, has no numbness or tingling, and is able to walk without a limp.  He was born at 38 weeks gestation via a spontaneous vaginal delivery with no complications.  The patient has met all developmental milestones, and all of his immunizations are up to date.  His father was recently diagnosed with hypertension at age 55, but there is no other significant family history.  Temperature is 36.1 C (97 F), blood pressure is 135/88 mm Hg in the right upper extremity, pulse is 110/min, respirations are 24/min, and pulse oximetry is 98% on room air.  Weight and height are at the 25th and 50th percentiles, respectively, for age.  Physical examination shows a well-appearing boy who has no dysmorphic features and who smiles and fully cooperates.  The lungs are clear to auscultation.  Heart rate and rhythm are normal.  A 2/6 continuous murmur is heard over the left interscapular area.  The lower extremities have no swelling, erythema, or tenderness.  Further evaluation would most likely show which of the following findings?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be04_d257_8f63_3d996243e62f_MD0005_00 This patient with right upper extremity hypertension, lower extremity claudication, and a heart murmur likely has aortic coarctation. The defect is usually congenital and located distal to the left subclavian. Although notoriously associated with Turner syndrome, aortic coarctation is most commonly sporadic and affects male patients. Findings are caused by impaired perfusion distal to the coarctation, and the degree of narrowing determines the severity of symptoms. Neonates with severe coarctation are at risk for life-threatening heart failure (HF) and shock following patent ductus arteriosus closure. However, milder narrowing of the aorta is often asymptomatic and diagnosed later, such as during childhood. Inadequate lower extremity perfusion may cause leg pain during exercise (claudication), as in this patient. In addition, 4-extremity blood pressure measurement classically shows upper extremity hypertension with lower extremity hypotension. Weak/delayed distal pulses (brachiofemoral delay) are also characteristic. Cardiac examination may reveal a continuous murmur due to blood flow through collateral circulation, a systolic murmur at the left sternal border from turbulent flow across the narrowed aorta, or no murmur if no other cardiac defects (eg, bicuspid aortic valve) are present. Chest x-ray reveals characteristic rib notching from collateral vessels and a figure "3" sign at the site of aortic narrowing. Echocardiogram confirms the diagnosis. Chest x-ray (Choice A) Digital clubbing is expected with cyanotic heart disease due to right-to-left shunting. However, this patient's oxygen saturation is normal. (Choice B) Patent ductus arteriosus closure in a newborn with severe coarctation can lead to HF, causing hepatomegaly due to hepatic congestion. However, coarctation presenting later in childhood, as in this case, is typically mild and rarely causes HF. Also, HF is unlikely in this patient with no other signs, such as dyspnea or pedal edema. (Choice D) Parasternal heave occurs with right ventricular hypertrophy. In contrast, aortic coarctation causes left ventricular overload due to impaired emptying against increased aortic pressure. (Choice E) Pulsus paradoxus is a large decline in blood pressure (>10 mm Hg) during inspiration that occurs with cardiac tamponade. The presentation typically includes chest pain, dyspnea, hypotension, jugular venous distension, and muffled heart sounds, findings not present in this patient. Educational objective: Aortic coarctation is a congenital narrowing of the aorta. Patients with mild narrowing may have claudication due to decreased blood flow distal to the aorta. Key findings include upper extremity hypertension, lower extremity hypotension, and weak/delayed distal pulses. References: Coarctation of the aorta: management from infancy to adulthood. (http://www.ncbi.nlm.nih.gov/pubmed/26635924)

A 6-Year-Old Boy Is Brought to the Office by His