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Clinical Case 22
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1

You are asked to see a 10 year-old boy for evaluation of pain in his legs which follows soccer practice or riding his bicycle. He has had no syncope or presyncope. His parents report that this has only been a problem over the past season. He has had no complaints of shortness of breath, chest pressure or other cardio-respiratory symptoms and easily keeps up with his peers in practice and in games. There is no family history of cardiac disease or sudden death. His past history is notable only for an ‘innocent’ heart murmur found on a physical when he was a preschooler (his parents do not recall if this was mentioned prior to that time). He is alert, cooperative and has no complaints at the time of the visit. His vital signs and growth parameters are normal.

Which of the following physical examination maneuvers would be most likely to provide vital diagnostic information in this child?
A)Auscultation for pulsus paradoxus
B)Cardiac auscultation at the base of the heart in standing and squatting positions
C)Measurement of blood pressure in all four extremities
D)Observation of jugular venous pressure wave, with and without hepatic pressure
E)Palpation for brachio-radial pulse delay





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