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coarctation of aorta
1
physical examination
Clinical Scenario
chest X-ray of Mr. A
Mr. A, a 30 yearold previously healthy man from Bangladesh is sent to your clinic for a compulsury medical check-up as a prerequisite for him to work in Malaysia.
He is currently well, but is unable to tell sufficient history due to his inability to speak english or bahasa, nor we don't have the ability to speak Bangladeshy.
eyes are normal, no jaundice no pallor. no ptosis / proptosis etc
some impacted ear-wax on the left ear
...what do we have here?
there is a previously corrected cleft-lip scar
carotid pulse palpated normally bilaterally
oral hygene is fair, with few caries.
Vital Signs ;
BP - 150/75 on right bracheal artery, patient lying 45deg. propped up upon rest.
Pulse rate 75 bpm, regular, fair volume - no radial-radial delay.
not tachypnec
PaO2 - 100%
generally patient well and cooperative, not in obvious pain. GCS full, hydration fair.
there is a soft murmur heard at the infra-clavicular region.
chest is of normal size and shape.
now you start to wonder, what can he be having, for him to have this various physical findings without symptoms?
there is a systolic murmur heard at between the scapula, as well as under left scapula.
upon auscultation, an ejection-systolic murmur is heard which is radiating to the axilla as well as carotids. it is accentuated when leaning forward.
what examinations would you like to perform?
what investigations would you like to order?
Notching of the posterior one-third of the third to eighth ribs
no aortic bruit
radio-femoral delay was attempted to be taken - femoral pulse was diminished.
because you're a GOOD physician, you proceed to check his health status top to toe.... and you notice some strange things.
femoral pulse was very difficult to palpate (which is weird, because you usually have no problem), so you decided to skip and come back later.
genitalia is normal.
characteristic 3 sign consisting of the enlarged and distorted aortic knob and subclavian artery forming the upper portion of the 3, the waist at the site of the coarctation (arrow), and the lower portion formed by the post stenotic dilatation of the proximal descending aorta.
comparing back the palm and the soles of the feet, the feet are definitely more pale compared to the palm, and the coldness of the feet is noted even more clearly.
you notice the foot is cold, and dry.
you also notice numerous scars which seemed to show poor healing.
normal X-ray for reference
your attempt to feel the lower extremity pulses have failed.