Case 15

74 years old female presented to the emergency department with worsening shortness of breath associated with abdominal distention.

On physical examination, she is afebrile, blood pressure
was 166/64 mm Hg, the heart rate 86 / minute and irregularly
irregular, the respiratory rate 18 / minute, and, Jugular venous distention
to the angle of the jaw when sitting upright was noted, as were
bibasilar rales. The apex beat of the heart was
enlarged, sustained, displaced leftward, and associated with
a right ventricular heave. There was a grade 3/6 blowing, pansystolic
murmur heard throughout the precordium, and a grade 1/6 diastolic
murmur audible at the left upper sternal border. No rubs or
gallops were heard, and there was no pericardial knock. The
patient's abdomen was distended, with a visible fluid wave,
and her liver was tender, pulsatile, and palpable 12 cm below
the right costal margin. She had peripheral edema (1+).

Echocardiogram showed evidence of tricuspid regurgitation

Which one of the following patterns 74 years old female presented to the emergency department with worsening shortness of breath in the jugular venous pulsation is typical of tricuspid regurgitation?

1. A giant A wave
   
2. A cannon wave.
   
3. A prominent C-V wave
   
4. A steep y descent.