View source for WBR0012

{{WBRQuestion
|QuestionAuthor=Aarti Narayan
|ExamType=USMLE Step 2 CK
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|Prompt=A 35 yr old woman presents to the out-patient department with symptoms of fatigue and dyspnea and pedal edema for the past 6 months. The symptoms were gradual in onset.  On examination, she was found to have hepatomegaly and mild ascites. She had a past history of Rheumatic fever. Echocardiographic studies show thickening and stenosis of tricuspid valve leaflets. What is expected finding on jugular venous pressure tracing?
|Explanation=The correct answer is giant ‘a’ wave. The patient in this vignette has developed right sided heart failure secondary to tricuspid stenosis, a condition nearly always caused by rheumatism.  Giant ‘a’ waves indicate that the right atrium is contracting against increased resistance. They are also seen in pulmonary hypertension and pulmonic stenosis.  The image above demonstrates an example of a Giant ‘a’ wave in a patient with pulmonary hypertension secondary to cardiomyopathy.  Note the absence of c and v waves in the JVP tracing.
|AnswerA=Absent ‘a’ wave
|AnswerAExp=Absent ‘a’ wave is seen in patients with atrial fibrillation.
|AnswerB=Deep ‘y’ descent
|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.
|AnswerC=Giant ‘a’ wave
|AnswerCExp=See Explanation
|AnswerD=Prominent ‘v’ wave
|AnswerDExp=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.
|AnswerE=Prominent ‘x’ descent
|AnswerEExp=Prominent ‘x’ descent is seen in constrictive pericarditis.
|RightAnswer=C
|Approved=No
}}