doing questions in UWorld, i got the following situation....if anybody has some good explanation, i will apreciate it because their explanation is quite poor expecially on the wrong answers:

65 year old man comes to the doctor for a follow-up regarding his poor control HTN. he has no complains except for some pain in the right thigh when he walks uphill or when he climbs stairs. past medical history: stable angina with a coronary angioplasty and stent 2 years ago, hypercholesterolemia, a 20 year history of HTN and a 10 year history of DM type 2. current medication: aspirin, metoprolol, hydrochlorothiazide, analapril, amlodipine, pravastatin, glyburide. he smokes 1 and a half pack of cigarettes per day. his physical examination does not reveal anything abnormal except for a BP of 160/100 in right arm and 180/100 in left arm. which of the following is the most likely diagnosis:

a. coarctation of the aorta
b. renal artery stenosis
c. pheochromocytoma
d. conn syndrome
e. cushing syndrome

Sounds to me like renal artery stenosis
This patient has elevated Bp despite several medications.
He has risk factors for hyperlipidemia and could have atherosclerotic renal artery stenosis

i encountered that q yesterday and i picked ( renal art stenosis )

cuz i felt there is something fishy about coarctation in that q :

1st why should he give all these info about coarctation .

2nd the pt age gives one point to stenosis knowing that he is compliant with his htn ttt.

3rd why should a pt with coarctation experience leg pain on exertion , i mean if there was some poor perfusion to the leg it should ve been acute if it was coarctation , but being on exertion give another point to atherosclerosis = stenosis .

4th and the most sure thing is ( where is the sudden sever tearing chest pain if it was coarctatio ) .

well guys, couple of things....
first of all thanks for the time and explanations
second: reason why i post this topic....doing questions i had a similar scenario to this one but the patient was younger...to be onest with you i can't remember everything but i'm pretty sure it was arround 30 year of age and for about 10 years he was diagnose with DM type 1....on top of that he was smoking for another 10-15 years....like i said i don't remember why he was presenting to the doctor but i can tell you for sure that he got an chest x-ray....nothing was wrong with that x-ray and at the end of the scenario they said the xray shows a '3 sign' and they ask us which is the most likely diagnosis; of course it is aortic coarctation.....if this guy at 30 years has HTN due to coarctation, why not the 65 year old could have pretty much the same scenario like the 30 year old but seen it later on in time? it is a tricky, or how you call it, 'fishy' question; unfortunatelly on the 65 years guy the only explanation what UWorld gave it was his risk factors(DM, high cholesterol, smoking, etc) and a history of poor HTN which can be explain only by renal stenosis(out of the posibilities given)....for the rest of the wrong answers(including coarctation) they didn't say anything about why that answer could not be right(the only explanations were what you will find on lab and physical exam: increase cortisol for cushing, increase urinary VMA for pheochromocytoma, increase costal artery circulation for coarctation).
bottom line: i gave you both patients to see maybe why i post this topic. when i saw the question with the 65 year old guy, in my mind i had this 30 year old which 'transform' in time into he old guy....later on i review the question and i admit i choose to fast the answer because there are very little chances for the 30 year old to survive that much without any cardiac problem.....and to be onest with you that difference in BP between right and left arm totally point me towards the wrong answer.
one more time thank you so much for your time and wish all of you good luck.

.....poor control HTN(he is hypertensive!!!)......pain in the right thigh when he walks uphill or when he climbs stairs(he has atherosclerosis)......stable angina with a coronary angioplasty and stent 2 years ago, hypercholesterolemia, a 20 year history of HTN and a 10 year history of DM type 2(All these are risk for more atherosclerosis, if he has it in one place in his body he can have it in almost any place in his body!!!!).......metoprolol, hydrochlorothiazide, analapril, amlodipine(that is a lot of anti-HTM medications)......BP of 160/100 in right arm and 180/100 in left arm (this is supposed to throw you off because coarctation will present with difference in BP in upper and lower extremities not in just the two opposite upper extremities)

b. renal artery stenosis (the patient's development of atherosclerosis has gone so out of control that it has started to stenose his renal arteries, likely both of them, and this will result in decreased flow to the kidneys which will cause the kidneys to think that the body is hypotensive or fluid depleted and thus the renin-angiotensin-system will be activated to raise the blood pressure even more, this is what is happening in this patient, thus he is not responsive to anti-HTM medication, and need to get his renal arteries fixed)

Dont worry it was a tough question, I got it wrong, but if thought through it I could have just picked the right answer based on just eliminating all the other answers.

i did this Q wrong BUT the BAD part was NO ACCEPTABLE ANSWER IN UWORLD EXPLANATION TO WHY IT CANT BE COARCTATION ?????
i have seen in many Uworld Qs the explanation is not good

hi there....this is the reason why i post this topic....on this particular question uworld does not give good explanations on the wrong answers....few other guys post why renal stenosis is THE BEST ANSWER and not coarctation....it's the only thing which we could do when we are dealing with this type of issues....

renal artery stenosis...

old age

atherosclerosis... high BP

Well always remember guys, in USMLE exam, there is more than one correct answer for each question. But we need to pick THE BEST ANSWER and the best answer in this scenario was Renal Artery Stenosis.