You have received your COVID19 immunizations but continue to practice telemedicine.
You are sent a video of a patient's head and neck while he was sitting in his hospital
bed (Panel A below). You are given no other information.
What is your diagnosis, what test(s) would you order to confirm your suspicions, and
what treatment, if any, do you recommend?
DIAGNOSIS: Severe aortic isufficiency with an abrupt systolic rise and diastolic fall
in the patient's carotid arteries. With the patient's head released from the pillow
this would produce a Musset's sign - a rythmic bobbing or nodding of the head in synchrony
with the heart beat. Some other signs of a widened pulse pressure are shown below
in the videos. Signs not shown include: Watson's water hammer pulse; Durozier's sign
(diastolic murmur over femoral artery when compressed with the bell); and Mayne's
sign (≥ 15 mm Hg drop in diastolic BP on raising the arm).
Insufficiency of the aortic valve may result from rheumatic fever, syphilis,
bacterial endocarditis, Marfan syndrome, Loey-Dietz syndrome, dissecting aneurysm,
aneurysm of Valsalva sinus, and aortic arch trauma. The insufficiency murmur (click
here) is diastolic, high pitched, blowing, and best heard in expiration with the patient
leaning forward. Aortic insufficiency due to aneurysm radiates along the right sternal
border; aortic insufficiency due to valvular disease radiates to the right second
and left third intercostal spaces.
Musset's sign in a patient with severe Quincky pulse in a patient with a wide
pulse
aortic insufficiency pressure. Note
the alternate blanching and filling
of the nail bed capillaries.
Müller's sign in a patient with severe aortic
insufficiency. Note the systolic bobbing of
the palate and the internal carotid arteries.
Bonus Question: What is your diagnosis? Answer: Giant (cannon) A waves and rapid V descent due to severe tricuspid insufficiency.
