Physical Exam Findings

    Jugular Venous Pressure

    • Jugular veins act as manometer tubes for the right atrium.  
    • How to identify:
      • Internal jugular vein lies deep to the sternocleidomastoid - often difficult to see.
        • 1. It is biphasic
        • 2. It is between two heads of the SCM
        • 3. It is non-palpable
        • 4. It is occludable
        • 5. It varies with respiration
        • 6. It responds to Hepato-jugular reflex.
      • There are two areas where you can see it.
        • 1. Between two heads of the SCM right superior to the clavicle.
        • 2. At the angle of the jaw.
        • Often times it is occluded by the two heads of the SCM and not seen.
        • Landmarks_of_jvp_opt.png
      • Can you use the external jugular vein?
        • Short answer is no: it takes a hairpin turn, and has valves, and only reflects RA pressures if person is on a ventilator 


    Pulsus Paradoxis

    • BP variation between breaths.
    • Normally during inspiration the intrathoracic pressure drops causing decreased preload, and decreased systolic BP.
    • Pulsus Paradoxis exhists if difference >12mmHg.
    • Done by measuring BP as patient breathes.  Deflate until hear Korotcoff sounds, then wait until inspiration and deflate some more to find insp pressure.
    • Positive in:
      • Cardiac Disease (Tamponade, Pericardial Effusion) - b/c those are preload dependent.  Resp changes preload.
      • Pulmonary Disease (Tension Pneumothorax, severe asthma)


    Congestive Heart Failure Exam


    Hepatojugular Reflux

    • Patient supine 45°
    • Apply 30-35mmHg to RUQ of patient for 10s.
    • Elevation of ≥3cm is positive.
      • (Based on original publication Maranz et al 1990 - Clinical Investigations - Used in JAMA RCE).

    Valsalva Maneouver

    • BP cuff inflated 15mmHg over patient's systolic BP, and listen over the antecubital fossa.
    • In normal patient: Once valsalva initiated, initial pressure rises and hear ≥ 2 beats (pressure helps eject blood, raises BP), and then sounds disappear (heart loses venous return).  Once valsalva released, heart recovers and sounds reappear ("overshoot", increased venous return causes increase in CO = higher BP to "overshoot"). 
    • In abnormal patient one of two happen:
      • With initiation of valsalva, hear ≥2 beats, then they disappear as normal, but do not return once valsalva is released ("Sine Wave Response")
      • With initiation of valsalva, hear ≥2 beats, but they don't disappear ("Square Wave Response").
        • (Based on original publication Maranz et al 1990 - Clinical Investigations - Used in JAMA RCE).
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