**Question:** A 27 year old man is noted to have blood pressure of 170/100 mmHg. He has prominent aortic ejection click and murmurs heard over the ribs on both sides anteriorly and over the back posteriorly. In addition, the pulses in the lower extremities are feeble and he complains of mild claudication with exercise. The most likely diagnosis is:

A. Aortic stenosis
B. Coronary artery disease
C. Aortic regurgitation
D. Coarctation of aorta

**Correct Answer:** D. Coarctation of aorta

**Core Concept:**
Aortic coarctation is a congenital cardiovascular disorder where the aorta becomes narrowed, typically between the origins of the brachiocephalic trunk and the left subclavian artery. This narrowing leads to decreased blood flow in the lower body and increased flow in the upper body, resulting in hypertension and various clinical manifestations.

**Why the Correct Answer is Right:**
The patient presents with hypertension (blood pressure gradient of 100 mmHg), prominent aortic ejection click, and murmur heard over the ribs and back due to increased blood flow and turbulence in the narrowed aorta. The feeble pulses in the lower limbs and mild claudication on exercise are also indicative of reduced blood flow to the lower limbs.

**Why Each Wrong Option is Inaccurate:**
A. Aortic stenosis: This condition involves a narrowing of the aortic valve, not the main aorta. The clinical presentation would differ significantly, with chest pain, syncope, and heart failure being more common in aortic stenosis.

B. Coronary artery disease: This condition results in myocardial ischemia, not hypertension and peripheral symptoms. Coronary artery disease is typically associated with angina and ischemic heart pain in the setting of hypertension.

C. Aortic regurgitation: This condition involves the aortic valve leaking, not narrowing, resulting in decreased blood flow to the heart and increased flow to the rest of the body. Clinical presentation would differ significantly, with fatigue, dyspnea, and heart failure being more common in aortic regurgitation.

**Clinical Pearl:**
Coarctation of the aorta is a rare congenital anomaly that may be missed in physical examination if not specifically looked for. In this case, the patient presents with hypertension, pulse differences, and symptoms of decreased blood flow to the lower limbs. Early recognition and intervention are crucial to prevent long-term complications, such as aortic aneurysm and dissection.