Vital Signs

I think this is a good case!

A 30 year old Asian woman presents to your clinic complaining of fatigue, weight loss, and low-grade fever. You send off some basic labs, reassure her, and send her home. The lab results show a normochromic normocytic anemia but are otherwise unrevealing. You put her on iron.

She presents a year later and you're surprised because now she looks sick. She complains about arm and leg pain with use. Sometimes when she uses her arms while cleaning, she gets dizzy. You get a "pan-positive review of systems"; she's noticed arthralgias, myalgias, chest pain, dyspnea, vertigo, orthostasis, headaches, abdominal pain, and diarrhea.

On physical exam, she's febrile to 38.4. Her pressures are 110/60 in her left arm, 95/50 on her right arm, and 150/90 with a wide cuff on her right thigh. The nurse had trouble taking the pulse. You feel her extremities and they're surprisingly cold. Her pulse is weak and asymmetric. You hear bruits over the subclavian arteries, brachial arteries, carotid arteries, and abdominal vessels.

Lab results show a normal white count, a normocytic normochromic anemia, elevated ESR, elevated CRP, hypoalbuminemia.

Challenge: Wow, the pressures are like reverse-coarctation! What's going on?