Question

A chest radiograph obtained in a male with hypertension. What will be the diagnosis?

• A. Tetralogy of Fallot
• B. Ebstein's anomaly
• C. TAPVC
• D. Coarctation of aorta

Hint:

Young hypertensive male: look at the rib undersurfaces and the aortic knuckle for a number 3.

Answer 1

The Correct Option is D

Step 1: Use the clinical clue. Hypertension in a young male, especially upper-limb hypertension, should make you think of coarctation of the aorta.
Step 2: Read the film. Look at the undersurfaces of the posterior ribs: notching is present because dilated, collateral intercostal arteries erode the lower rib borders. The aortic contour shows the classical 'figure-3 sign', where the indentation at the coarctation site replaces the normal aortic knuckle.
Step 3: Combine. Rib notching plus the figure-3 sign with a normal-sized heart confirms coarctation of the aorta.
Why the others are wrong: TOF gives a boot-shaped heart with oligaemic lungs, Ebstein's gives a huge box-shaped heart, and TAPVC gives a snowman shadow, none of which fit hypertension with rib notching.
Ref: Bailey and Love, Short Practice of Surgery, 27th edition, Page 906.