The jugular venous pulse contour in our patient gives us much pathophysiologic information. Note especially the "a" wave that precedes the carotid impulse. We'll use the cotton swab to define that carotid impulse by observing its movement in systole. [Cut-away]
Our patient has a markedly increased, gigantic "a" wave in the jugular venous pulse and, in fact, that wave is called a giant "a" wave and tells us something very important. That right atrium is struggling to push blood into the right ventricle and is meeting resistance either at the level of the valve or at the level of the ventricle itself. It also tell us something very important as an overview, our patient has some form of right heart disease the etiology of which is to be determined.
Normal vs. giant "a" graphics
By comparing the graphic of a normal patient to our patient, we can appreciate that our patient's "a" wave is larger. An abnormally prominent, or giant, "a" wave is due to enhanced right atrial contraction against an increased resistance. This is most often due to right ventricular hypertrophy.