Background
A 70-year-old female presented with a three month history of progressive exertional angina and left upper extremity claudication, despite maximum medical treatment.
She also reported left upper extremity pain, which was associated with dizziness and exacerbation of angina. She had no syncope.
Onset: Three-months.
Duration: Each episode lasts two to five minutes.
Past Medical History
Atherosclerotic heart disease with coronary artery bypass graft surgery two years prior.
Diabetes mellitus.
Hypertension.
Mild mitral valve regurgitation.
Family History: Sister with acute myocardial infarction at the age of 50.
Social/Occupational History: Nonsmoker, nondrinker.
Physical Findings
Weight: 128 lbs
Pulse: 70 Regular.
Blood Pressure: Right arm: 140/70 mm Hg; Left arm: 100/62 mm Hg
Head and NEck examination shows Bilateral carotid bruits, left louder than right.Chest and Lungs are Clear to auscultation.Cardiac Exam rvealed Soft systolic murmur over the apex, otherwise normal.Abdomen is Noncontributory. Weak and delayed pulse in the left radial, brachial, and axillary arteries.Neurologic examination is Within normal limits.
Which is most likely to be responsible for the weak pulse in the left upper extremity in this patient?
Click here for diagnose
If carotid and vertebral artery Doppler was performed in this patient, what is the most likely finding?
Correct Answer:Reversal of Blood flow in the left Vertebral artery
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