Review Question - QID 106277

The medical student on the pediatric cardiology team is examining a 9-year-old girl who was referred by her primary care physician for unexplained hypertension. She is accompanied by her mother who reveals that the child is generally well but has been significantly less active than her peers for the past year. On exam, the medical student notes a thin girl in no apparent distress appearing slightly younger than stated age. On exam, her blood pressure is 160/80 mmHg, pulse is 80/min, and respirations are 16/min. Physical exam reveals a 3/6 systolic ejection murmur at the upper left sternal border, but otherwise, the cardiac exam is normal. Pedal pulses could not be palpated. Which of the following physical exam findings was most likely missed by both the medical student and primary care physician?