An 18-year-old boy is found during a school screening to have BP 165/95 mmHg in both arms. Popliteal cuff pressure is 110/70 mmHg, femoral pulses are delayed relative to radial pulses, and there is a soft systolic murmur heard over the left interscapular area. Chest radiograph shows rib notching. What is the most likely diagnosis?
- A Pheochromocytoma
- B Renal artery stenosis
- C Coarctation of the aorta ✓
- D Liddle syndrome
Correct answer: C. Coarctation of the aorta
Explanation
Upper extremity hypertension with lower extremity hypotension, radiofemoral delay, an interscapular systolic murmur, and rib notching from dilated intercostal collaterals is classic for aortic coarctation. Renal artery stenosis can cause brachiofemoral delay in severe bilateral disease but would not produce rib notching or an interscapular murmur. Pheochromocytoma gives paroxysmal hypertension with catecholamine symptoms rather than differential limb pressures. Liddle syndrome presents early with hypokalemic alkalosis, which is not described here.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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