The answer is c Seidel 4e pp 476478 Coarctation of the aorta

is narrowing of the aorta usually just distal to the origin of the ductus arte-riosus and subclavian artery. Patients may complain of epistaxis, headache, cold peripheral extremities, and claudication. Absent, delayed, or markedly diminished femoral pulses may also be found. The low arterial pressure in the legs in the face of hypertension in the arm is also a clue toward the diagnosis. Chest radiograph in coarctation shows rib-notching secondary to the dilated collateral arteries. PDA is associated with a loud, continuous murmur. Tetralogy of Fallot consists of VSD, pulmonic stenosis (PS), dextroposition of the aorta, and right ventricular hypertrophy (RVH).

164. The answer is d. (Fauci, 14/e, p 1339.) A pericardial knock is an early mid-diastolic sound and is due to constrictive pericarditis. The diagnosis is confirmed by showing a thickened pericardium on CT scan or MRI. The treatment is pericardiectomy. Constrictive pericarditis may be idiopathic (60% of cases) or due to tuberculosis, mediastinal irradiation, or cardiac surgery. Restrictive cardiomyopathy is the least common form of cardiomyopathy; potential etiologies include sarcoidosis, amyloidosis, and hemochromatosis. Often the patient with restrictive cardiomyopathy presents with other signs of the systemic illness.

165. The answer is c. (Sapira, pp 360-361.) The Kussmaul sign (inspiratory distension of the neck veins) is seen in right ventricular infarction, right heart failure, constrictive pericarditis, superior vena cava syndrome, and tricuspid stenosis. Inspiration normally generates a negative intrapleural pressure, which sucks blood into the heart. With certain diseases, there is impairment of right heart filling and blood cannot enter the heart, causing venous pressure to rise. In these patients, inspiration will cause a paradoxical rise in venous pressure (Kussmaul sign). The Kussmaul sign is never seen in uncomplicated cardiac tamponade. Right ventricular infarction is seen in up to 30% of inferior wall infarctions; patients usually present with hypotension and raised venous pressure (Kussmaul sign).

166. The answer is d. (Goldman, 21/e, p 284. Sapira, pp 304-305.) The ductus arteriosus, which is patent in the fetal circulation, may fail to close at birth. Patients with PDA may be asymptomatic or may complain of dyspnea, palpitations, and exercise intolerance. The pulse pressure is usually widened and pulses are bounding due to the runoff of blood through the ductus. The continuous "machinery" murmur of PDA is best heard in the 1st-2nd ICS below the left clavicle. Other continuous murmurs include the cervical venous hum (due to increased blood flow in the internal jugular vein; disappears with compression of the vein), the hepatic venous hum (disappears with compression of epigastrium), and the mammary soufflé (heard over the breast due to increased blood flow in pregnancy).

167. The answer is d. (Sapira, p 285.) The left parasternal border at the third, fourth, and fifth intercostal spaces should be palpated for a right ventricular tap, which is also called a lift or heave. It is a nondiag-nostic finding and results from any etiology of right ventricular hypertrophy. A heave that is palpable at the apex is consistent with LVH.

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