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Gereal Signs

General Examinations

JVP for Fluid status of Patient

Angle of louis

alt text - Level of Right atrium - Tracheal Bifurcation - thoracic duct crosses over - azegous vein joining IVC - lower boarder of T4 - T2 joing sternum => below is T2 intercoastal space

How to Measure the Jugular Venous Pressure (JVP)

  1. Get the patient to relax, raise the bed so you are not straining.
  2. Take the pillow away; the waveforms are often better seen with the head lying directly against the examining table/bed.
  3. Position the neck until you have the best view.
  4. If you make sure the room is well lit, there is no need for shining a flashlight, penlight or other direct light.

  5. Make your first goal just to see a pulsation, and then decide if it is arterial or venous by applying the following criteria to identify venous waves:

    • Venous wave is bifid, flicking like a snake's tongue.
    • It rises when you lower the head of the bed and sinks when you raise the head of the bed.
    • It changes with respiration, sinking into the chest with inspiration.
    • It is not palpable.
      • It is fine to use the external jugular vein, as long as you can see clear wave forms in it.
    • Commonly, a prominent pulsation is mistaken for that of the carotid artery rather than of the JVP. To differentiate, press on the RUQ while watching the neck. The JVP should rise in all individuals with this maneuver; whereas a carotid pulsation should not change.

  6. The JVP can be assessed on either the right or left. On occasion (musculoskeletal anatomy, venous clots) the pulsations can only be visualized on one side. If you cannot clearly define the JVP on the right internal jugular, examine the left.

  7. If you cannot determine the JVP, report the exam as "JVP not visualized" rather than "no JVD" (which implies that the JVP was visualized and is not elevated).

Once you have determined that you are seeing the venous waves then measure the jugular venous pressure:

  1. Identify JVP at the highest point of pulsation
  2. Extend card or ruler horizontally from highest pulsation point , cross with ruler placed on the sternal angle (Angle of Louis), (let's say it was 8cm).
  3. Add 5 cm (to get to the center of the atrium) and then report the JVP as "the jugular venous pressure was 13 cm of water" (not mercury).

Percussion of Lungs

Shifting Dullness in Ascites

+Shifting Dullness](https://www.youtube.com/shorts/gY30zcQYcj8)

Ascites Fluid Thrill