The patient who keeps coming back with abdominal fullness, leg oedema and a rising creatinine on escalating furosemide is often carrying severe tricuspid regurgitation that nobody has graded. Right-sided congestion of this kind is easy to attribute to the left ventricle, to renal failure or to age, and the echo report frequently mentions the tricuspid valve last.
Three bedside signs raise it early. A large systolic wave in the jugular venous pulse that you can see from the end of the bed; a pulsatile liver edge on gentle palpation during quiet respiration; and ascites out of proportion to peripheral oedema. Together they should prompt a specific request rather than a routine one.
Ask the echocardiographer directly for tricuspid regurgitation severity, right ventricular size and function, and an estimate of pulmonary artery systolic pressure. Those three answers decide whether the problem is a valve that can be treated or a right ventricle that has already failed, and they are the same three that any structural referral will need.
- Look for a visible giant systolic jugular wave before touching the abdomen
- Palpate for a pulsatile liver in anyone with refractory right-sided oedema
- Ask explicitly for TR severity, RV size and function, and estimated PA systolic pressure
- Reconsider before escalating diuretics again in a patient whose creatinine is climbing
- Record the diuretic dose and adherence: a valve referral will be judged against what medical therapy was truly tried
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