MEDizzy - You are evaluating Mr. Estebez, a 67-year-old owner of a

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Disorders of the Cardiovascular System

You are evaluating Mr. Estebez, a 67-year-old owner of a wildly successful chain of sushi restaurants. He complains of shortness of breath with exertion, lower extremity edema, and awakening at night feeling acutely short of breath. You wish to assess his volume status and know that jugular venous pulse (JVP) assessment is the single most important physical examination measurement to aid you in this component of your evaluation. Which of the following statements regarding JVP measurement is true?

ExplanationJugular venous pulse (JVP) is the single most important physical examination measurement from which to estimate a patient’s volume status. The internal jugular vein is preferred because the external jugular vein is valved and not directly in line with the superior vena cava and right atrium. Precise estimation of the central venous or right atrial pressure from bedside assessment of the jugular venous waveform has proved difficult. Venous pressure traditionally has been measured as the vertical distance between the top of the jugular venous pulsation and the sternal infection point (angle of Louis). A distance >4.5 cm at 30 degrees of elevation is considered abnormal. However, the actual distance between the mid-right atrium and the angle of Louis varies considerably as a function of both body size and the patient angle at which the assessment is made (30, 45, or 60 degrees). The use of the sternal angle as a reference point leads to systematic underestimation of central venous pressure (CVP), and this method should be used less for semi-quantification than to distinguish a normal from an abnormally elevated CVP. Venous pulsations above the right clavicle in the sitting position are clearly abnormal, as the distance between the clavicle and the right atrium is at least 10 cm. Normally, the venous pressure should fall by at least 3 mmHg with inspiration. Kussmaul sign is defined by either a rise or a lack of fall of the JVP with inspiration and is classically associated with constrictive pericarditis, although it has been reported in patients with restrictive cardiomyopathy, massive pulmonary embolism, right ventricular infarction, and advanced left ventricular systolic heart failure. It is also a common, isolated finding in patients after cardiac surgery without other hemodynamic abnormalities.