|Author||Aarti Narayan (Edited by Ayokunle Olubaniyi and Alison Leibowitz)|
|Exam Type||USMLE Step 2 CK|
|Main Category||Internal medicine|
|Prompt||A 35-year-old woman presents to the outpatient department with gradually worsening symptoms of fatigue, dyspnea, and pedal edema over the past 6 months. There is a past medical history of rheumatic fever. The physical examination is positive for hepatomegaly and mild ascites. Echocardiographic studies show thickening and stenosis of tricuspid valve leaflets.
Which of the following findings on the jugular venous pressure (JVP) tracing is most likely to be observed in this patient?
|Answer A||[[AnswerA::Absent ‘a’ waves]]|
|Answer A Explanation||[[AnswerAExp::Absent ‘a’ waves are seen in patients with atrial fibrillation.]]|
|Answer B||Deep ‘y’ descent|
|Answer B Explanation||[[AnswerBExp::Deep ‘y’ descent is seen in early diastole with severe tricuspid regurgitation. It is also seen with constrictive pericarditis and severe right ventricular failure.]]|
|Answer C||[[AnswerC::Giant ‘a’ waves]]|
|Answer C Explanation||This is the correct answer.|
|Answer D||Prominent ‘v’ wave|
|Answer D Explanation||Prominent ‘v’ wave results from increased volume of blood in right atrium during ventricular systole and is seen in tricuspid regurgitation. It is also seen with constrictive pericarditis and severe right ventricular failure.|
|Answer E||Prominent ‘x’ descent|
|Answer E Explanation||[[AnswerEExp::Prominent ‘x’ descent is seen in constrictive pericarditis.]]|
The image above shows a normal jugular venous pressure tracing.
The patient in this vignette has developed right-sided heart failure secondary to tricuspid stenosis, a condition which is usually a late complication of acute rheumatic fever. Giant or prominent ‘a’ waves are the hallmark of tricuspid stenosis in patients who are in sinus rhythm, and it indicates that the right atrium is contracting against increased resistance. Other examples where giant ‘a’ waves can be seen include: pulmonary hypertension, pulmonic stenosis and right atrial myxoma.
|Keyword||Rheumatic fever, tricuspid stenosis, a wave, prominent a wave, giant a wave|
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