Summary
In reviewing this case, the initial emphasis is on the patient's history. You should always read the history prior to the exam.

Note:

• The patient is an infant which may indicate congenital malformations.
• Lower extremity edema and cyanosis can be indicators of reduced blood flow to that region.
• Heart sounds can give you important information on abnormal flow patterns and in this case a continuous murmur lets you know that there is collateral circulation, the aortic ejection sound and ejection murmur indicate aortic valve malformation like a bicuspid valve with a reduced orifice, accentuated A2 indicates forceful aortic ejection, a systolic thrill may indicate that the bicuspid valve is stenotic with the sound radiates to the suprasternal notch during systole following the direction of flow, a diastolic murmur may mean the bicuspid valve may also be incompetant and aortic regurgitation may be present.
• Radial-femoral pulse delay is a key feature in coarctation as flow is diminished to lower extremities.
• Left ventricular thickness is increased, left atrial dilatation may be present.
• Watch for eccentric opening of the aortic valve in the PLAX view.
• Watch for any flow aliasing in color flow indicating high velocity turbulent flow and also for retrograde flow indicating regurgitation.
• In PSAX view examine the aortic valve for football-shaped opening and note absence of the normal triangular formation of leaflet separation during systole.
• Suprasternal view is the most important to identify the lesion, examine the region in the aortic isthmus for medial thickening; positions may be preductal, juxtaductal, or postductal which can pose varying signs and symptoms.
• Color flow imaging is helpful in finding the region of highest flow disturbance and velocity, calculating PISA can determine the flow acceleration proximal to obstruction.
• Doppler will demonstrate the flow patterns of increased systolic and diastolic velocities.
• 2D measurements should confirm the narrowest diameter of the coarctation to compare with the aorta proximal and distal to the lesion.