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  #1  
Old 04-12-2015
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Question Spasemaster Q7

A 23 year old male comes to the clinic with symptoms of muscle claudication when exercising. On examination you notice that the patients Blood pressure is 140/90 in the right arm and 100/60 in the right leg. What other clinical findings would you also find in this patient:

A-Notching of the upper border of ribs
B-Pan-Systolic murmur heard while auscultating the back
C-Decreased pulse count on the right leg in comparison to the right arm
D-Hyperreflexia in the right leg
E-Palpation of an abdominal Aortic aneurysm
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  #2  
Old 04-12-2015
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Looks like a postuductal coarctation, i would say A.
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Old 04-12-2015
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Quote:
Originally Posted by Hassan8 View Post
Looks like a postuductal coarctation, i would say A.
but isnt the notching on the under surface of the ribs? at first i was thinking c but then the pulse gets diminished, the count stays the same..
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Old 04-12-2015
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Ah you're right! This is a tricky one lol ! I think i would go with the murmur then. B??
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Quote:
Originally Posted by Hassan8 View Post
Ah you're right! This is a tricky one lol ! I think i would go with the murmur then. B??
yea i think so too. B
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decreased pulse
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Old 04-14-2015
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Correct Answer

Quote:
Originally Posted by spasemaster View Post
A 23 year old male comes to the clinic with symptoms of muscle claudication when exercising. On examination you notice that the patients Blood pressure is 140/90 in the right arm and 100/60 in the right leg. What other clinical findings would you also find in this patient:

A-Notching of the upper border of ribs
B-Pan-Systolic murmur heard while auscultating the back
C-Decreased pulse count on the right leg in comparison to the right arm
D-Hyperreflexia in the right leg
E-Palpation of an abdominal Aortic aneurysm


Yes, It is B-Pan-Systolic murmur heard while auscultating the back.
They like the point that you can hear the murmurs while auscultating the back in USMLE. The murmur is due to turbulence in the aorta during systole and stenosed part of it also.

A-Notching is supposed to be on the lower border of the rib as that's where the vascular bundle is.
C-There's a decrease in pulse strength BUT NOT the number (It's same hear rate all over the body)
D-There's no neurological deficit due to the coarcatation.
E-Decreased probability of an abdominal aneurysm due to decreased blood flow.



You order a CXR for the same patient and find notching on the lower border of the ribs. The notching is due to dilatation of which Blood Vessel:
A-Internal thoracic Artery
B-Anterior Intercostal Artery
C-Posterior Intercostal Artery
D-Mammary Artery
E-Intercostal Vein
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Old 04-14-2015
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B ?

My reasoning:

Subclavian--->Internal thoracic--->Anterior Intercostal-->posterior intercoastal--->aorta

Anterior Intercoastal is related to the lower margin of the rib and has to carry the extra blood load in postductal coarctation to supply the blood to aorta
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Old 04-14-2015
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Yeah i'd go with B too. Actually im still a bit confused regarding the first question, though i did say b but isnt a systolic murmur heard at the back caused by a PDA and since this is an adult patient he would have a POST DUCTAL coarctation which is NOT assosciated with a PDA.
Any comments?
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Old 04-14-2015
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Quote:
Originally Posted by Hassan8 View Post
Yeah i'd go with B too. Actually im still a bit confused regarding the first question, though i did say b but isnt a systolic murmur heard at the back caused by a PDA and since this is an adult patient he would have a POST DUCTAL coarctation which is NOT assosciated with a PDA.
Any comments?
I think it's not specific to PDA, although heard in PDA in the back it could also be heard in coarcatation.
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Old 04-15-2015
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Got it thanks
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Old 04-15-2015
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Correct Answer

Most welcome Hassan.

Anyways, the answer to the second question is:
C-Posterior Intercostal Artery, Blood flows from the the internal thoracic Artery AKA "Mammary A." to the anterior intercostal A. and then flows into the posterior intercostal A. back to the Aorta.

So, there's back flow of blood through the posterior intercostal A which dilates it and causes notching of the ribs.
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