This patient presents with newly diagnosed hypertension and clinical features of aortic coarctation, which include upper extremity hypertension and a radial artery–to–femoral artery pulse delay suggesting a mechanical obstruction between the radial and femoral arteries; lower extremity blood pressure determinations may be low or difficult to obtain. A systolic murmur over the left posterior chest is common in patients with severe aortic coarctation; these murmurs can arise from the obstruction or the collateral blood flow. The chest radiograph (shown) demonstrates “rib notching” affecting several of the posterior ribs; rib notching results from exaggerated collateral blood flow diverting blood around the area of obstruction. Also present on the chest radiograph is the “figure 3 sign” caused by dilatation of the aorta above and below the area of coarctation.

Essential hypertension is the most common cause of hypertension in adults. A family history of hypertension is common. The physical examination in a patient with severe essential hypertension often includes an S₄, but a pulse and blood pressure differential between the upper and lower extremities is not expected.

Patients with hypertrophic cardiomyopathy do not usually present with hypertension. The systolic murmurs in hypertrophic cardiomyopathy characteristically include an ejection quality murmur at the left sternal border related to outflow obstruction and a late systolic murmur at the apex related to mitral valve regurgitation.

Renovascular hypertension is a common cause of hypertension occurring primarily in patients with diffuse atherosclerosis. An epigastric bruit may be audible. The rest of the physical examination in a patient with renovascular hypertension is usually normal. A pulse and blood pressure differential between an upper and a lower extremity is not expected.