Last Week's Medical Mystery

      You are practicing telemedicine and are asked to make a diagnosis in a 72-year-old man merely by looking at a video of his neck veins (see below).
      DIAGNOSIS: Positive Kussmaul sign and a and v waves in the external jugular veins of a patient with congestive heart failure.
      Kussmaul sign is the failure of jugular veins to collapse during inspiration; it is regarded as a reliable sign of decreased venous return to the right heart of whatever cause (e.g., right-sided heart failure [most common cause], right atrial myxoma [rare], tricuspid stenosis, constrictive pericarditis, restrictive cardiomyopathy, etc).
     Under normal circumstances inspiration decreases intrathoracic pressure thereby increasing venous return to the right heart. The consequent delay in right heart emptying plus the inspiratory expansion of the pulmonary vascular bed accounts for the increase in arterial pulse rates normally seen during inspiration. 

Failure of the neck veins to collapse during inspiration (Kussmaul sign). Barely seen are a and v waves (created during right atrial and right ventricular systole, respectively).                                                   

  BONUS QUESTION: What is your diagnosis? Answer: atrial flutter with varying degrees of block; status post anterior septal myocardial infarction.

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