GENERAL

 EXAMINATION  
 
1. Appearance  of  the  patient   Decubitus  
2. Built   Position  of  patient  in  the  bed  
3. Nutrition   1.  Orthopnea  
4. Intelligence  
Definition   Dyspnea  on  lying  down  which  is  relieved  by  
5. Cooperation  
sitting  upright  
6. Consciousness  
  • Left  sided  heart  failure  
7. Attitude  
  • Acutes  severe  asthma  
8. Vital  signs  
Causes   • Mediastinal  syndrome  
a) Pulse    
b) Blood  pressure   • Tense  ascites  
c) Temperature   • Advanced  lung  disease  
d) Respiratory  rate   2.  Platypnea  
9. Complexion   Definition   Dyspnea  on  upright  position  which  is  relieved  
a) Pallor   by  lying  down  
b) Jaundice     • Multiple  recurrent  pulmonary  emboli  
c) Cyanosis     • Bibasilar  pneumonia  
d) Malar  flashes   Causes   • Bilateral  pleural  effusion  
10. Head  neck  examination   • Bibasilar  arteriovenous  shunting    
11. Upper  &  lower  limb  examination   • Pulmonary  arteriovenous  malformation  
12. Skin  
13. Other  system  examination   3.  Talepnea  
  Definition   Dyspnea  on  lying  on  a  lateral  decubitus  
Built   position  
Definition   Relationship  between  height  &  span  according  to  age,     • Unilateral  pleural  effusion  
sex,  &  race   Causes   • Tension  pneumothorax  
Height   Measured  from  head  to  heal   • Destroyed  lung  
Span   Distance  between  distal  phalanges  of  middle  fingers  in   • Atelectatic-­‐consolidated  lung  
both  extended  arms   4.  Trepopnea  
Patient   Over  built   if  Height  >  Span   Definition   Patients  prefer  to  lie  on  a  lateral  decubitus  
may  be   Under  built   If  Span  >  Height   position  
either   Average  built   if  Height  =  Span     • Unilateral  lung  collapse  
    • Lung  abscess  
Nutrition   Causes   • Pneumonia  
A.  History  of   • Unilateral  pleural  effusion  
1.  Weight  loss  >10%  of  IBW   • Destroyed  lung  
2.  Anorexia   5.  Prayer's  position  
Definition   Patient  prefer  to  lean  forward  
3.  Persistent  vomiting  
  Leaning  forward  unload  the  pressure  effect  of  
4.  Prolonged  diarrhea   Mechanism   the  mass  or  the  gravitational  dependency  onf  
B.  Clinical   effusion  on  the  lung  &  other  mediastinal  
1.  Manifestations  of  vitamin  deficiency   structures  
2.  Lower  limb  oedema   Causes   • Pericardial  effusion  
3.  Athropometric  measurement   • Mediastinal  syndrome  
i.  Skin  fold  thickness  (indicator  of  fat)   6.  Professorial  attitude  
ü Suprapubic  fat:  1  inch  (males)  ,  >1  inch  (females)   Definition   Patient  stands  supporting  his  extended  arms  
ü Triceps  skin  fold  thickness:  1/2  inch   on  a  table    
ü Costal  skin  fold  thickness:  At  mid  axillary  1  inch     • This  position  fixes  the  shoulder  girdle    
  Mechanism   • Improving  the  action  of  accessory  
ii.  Mid  arm  circuference  (indicator  of  muscle  mass)   respiratory  muscles  
             #Normally  it  is  25cm   Causes   • COPD  (emphysematous  type)  
  • Acute  severe  asthma  
iii.  Patient's  waist  circumference    
ü With  the  patient  standing,  measures  the  waist  just  above  the    
hip  bones.    
ü Excess  body  fat  if  the  waist  measures:    
1. ≥ 35  inches  for  women    
2.  ≥  40  inches  for  men    
iv.  Ideal  Body  Weight    
             #Actual  weight  (in  Kg)  /  Ideal  weight  (in  Kg)  X  100    
             #Normally  it  is  100%    
             #Weight  loss  >10%  of  IBW  is  significant    
v.  Weight  to  height  ratio    
             #Weight  (in  Kg)  /  Height  (in  cm)    
             #Normally  =  0.4-­‐0.6    
vi.  Body  Mass  Index      
             #Weight  (in  Kg)  /  Height  (in  meters)!      
             #Normally  =  20-­‐24  Kg/m!    
   
   
   
   
   
 GENERAL  EXAMINATION  
 
Vital  Signs   pulsation  
• Pulse,  Blood  pressure,  Temperature,  Respiratory  rate   Brachial   • In  the  antecubital  fossa  medial  to  biceps  tendon  
• Pulse:  Comment  on  the  following  criteria     pulsation  
1.  Rate   Femoral   • Just  below  inguinal  ligament  midway  between  the  
Normal   60-­‐100  beat/min   pulsation   ASIS  &  symphysis  pubis  
Bradycardia   <60  bpm     • Felt  in  the  popliteal  fossa  at  the  level  of  knee  crease  
Tachycardia   >100  bpm   Popliteal   with  thmb  in  front  of  the  knee  &  finger  behind  
pulsation   • Press  firmly  in  the  midline  over  popliteal  artery  
2.  Rhythm  
• Normally  it  is  regular   Posterior   • Felt  by  the  pads  of  index  &  middle  fingers  2cm  
tibial  artery   below  &  behind  the  edial  malleolus  
• Irregularity  is  as  stated  below  
  Dorsalis   • Felt  in  the  middle  of  the  dorsum  of  the  foot  at  the  
• A.F    
  pedis   proximal  extent  of  the  groove  between  1st  &  2nd  
• Can't  count  4  successive  beats  
Irregular   artery   metatarsals  
• Do  the  following:  
irregularity   8.  Special  characters  (Pulsus  paradoxus)  
*count  the  pulse  from  the  apex  
*count  one  full  minute     • Exaggeration  of  the  normal  respiratory  variation  in  
  SBP  
• Measure  pulsus  deficit  (difference  between  apical  &  
Definition   • Normal  SBP  ↓  with  inspiration  <10mmHg  &  ↑  with  
radial  pulse  
Regular   expiration  
• Extrasystoles  
irregularity   • Can  count  >4  successive  beats   • Inspiratory  drop  of  SBP  >10mmHg  is  defined  as  
abnormal  pulsus  paradoxus  
Differences  between  Extrasystoles  &  A.F.  
  • Changes  in  pulse  volume  are  independent  of  the  
  Extrasystoles   A.F.  
Why  is  it   changes  in  pulse  rate  
Description   can  count  >4   cannot  count  4  successive  beats  
paradoxical   • Pulsus  paradoxus  is  detected  mainly  by  measuring  
successive  beats  
inspiratory  changes  in  SBP,not  by  feeling  the  
Pulsus   <10   >10  
peripheral  pulse  
deficit  
  • Inspiration  →  ↓  intrathoracic  pressure  &  ↑VR  to  the  
Carotid   Disappear   No  effect  
  right  ventricle  
massage  
  • Also  cause  ↓  left  ventricular  VR  (because  of  the  
Exercise   Disappear   No  effect     pooling  of  blood  in  in  the  inflated  lungs  &  left  shit  in  
ECG   P  present   P  absent     the  ventricular  septum)  
3.  Force,  Tension,  Volume     • Smaller  end  diastolic  left  ventricular  volume  →  ↓  
  =Systolic  blood  pressure:     stroke  volume  →  ↓  SBP  
Force   Minimal  pressure  applied  to  obliterate  the  pulse     • If  this  drop  is  severe  (>20mmHg)  →  palpable  
  =Diastolic  blood  pressure:     weakening  in  the  peripheral  pulse  
Tension   Minimal  pressure  applied  to  feel  the  pulse  maximally   Patho   • Exhalation  →  ↑  left  ventricular  filling  (because  of  the  
  =Pulse  pressure:   physiology   squeezing  of  blood  from  the  deflating  lungs  &  right  
Volume   Difference  between  systolic  &  diastolic  blood  pressure  
shift  in  ventricular  septum)  
Big  pulse  volume   • ↑  ventricular  filling  →  ↑  left  ventricular  stroke  
• Pulse  pressure  >50%  of  SBP   volume  &  ↑  SBP    
• Example:  Patient  with  140mmHg  (SBP)  &  60mmHg  (DBP),  the  pulse   • If  severe  enough  →  ↑  pulse  volume  
pressure  is  80  which  is  >70  (50%  of  SBP)     1. Fully  inflate  blood  pressure  cuff  until  you  achieve  
• Most  common  cause:     auscultatory  silence.  
1. Aortic  regurge     2. Start  deflating  the  cuff  slowly,  at  the  same  time  pay  
2. Hyperdynamic  circulatory  state     attention  to  chest  &  abdominal  expansion.  
Small  pulse  volume     3. As  soon  as  you  hear  the  1st  korotkoff  sounds,  stop  
• Pulse  pressure  <25%  of  SBP   How  to   deflating  the  cuff  &  record  the  pressure  reading.  You  
• Example:  Patient  with  100mmHg  (SBP)  &  90mmHg  (DBP),  the  pulse   measure   will  notice  that  sounds  can  be  heard  only  in  
pressure  is  10  which  is  <25  (25%  of  SBP)   pulsus   exhalation.  
• Most  common  cause   paradoxus?   4. Start  deflating  the  cuff  again  slowly,  until  you  hear  
1. A.S.   korotkoff  sounds  in  both  inspiration  &  expiration.  
2. M.S.   Record  the  pressure  reading.  
3. Constrictive  pericarditis   5. Difference  between  the  two  readings  is  the  pulsus  
4. Pericardial  effusion   paradoxus  
5. Myocardial  infarction     • Acute  severe   • Pleural  effusion  
4.  Equality  on  both  sides   Causes   asthma   • Pericardial  effusion  
• Normally  pulse  is  equal  on  both  sides  (regarding  the  volume  &  not   • Emphysema  
the  rate)    
• Causes  of  unequal  pulse   Complexion  
1. Cervical  rib  
Pallor,  Jaundice,  Cyanosis,  Malar  flushes  
2. Pancoast  tumor  
1.  Pallor  
3. Aortic  aneurysm  
  Reduced  or  absence  of  reddish  coloration  of  mucous  
4. Peripheral  embolism  
Definition   membrane  &  skin  of  the  palm  
5.  Condition  of  the  wall  
  1. Palm  of  the  hand  
• Examined  by  the  middle  3  fingers  
  2. Under  surface  of  the  tongue  
• If  felt  it  is  due  to  atherosclerosis  
Sites   3. Nail  bed  
6.  Radioradial  &  radiofemoral  delay  in  cases  of  coarctation  of  Aorta   4. Conjunctiva  
7.  Other  pulsations   5. Inner  surface  of  the  lip  
  • Felt  by  the  left  thumb  for  the  right  carotid  &  vice     Pallor  with  anemia  
Carotid   versa     1. All  types  of  anaemia  
pulsation   • Most  easily  palpable  at  the  angle  of  jaw  anterior  to     2. Anaemic  heart  failure  
sternomastoid  muscle      
Radial   • Felt  by  middle  3  fingers  over  the  right  radial      
 GENERAL  EXAMINATION  
 
  Pallor  without  anemia   Differences  between  peripheral  &  central  cyanosis  
  1. Rheumatic  activity     Peripheral   Central  
Causes   2. Aortic  regurge  &  Aortic  stenosis   Site   Affects  skin  only   Affects  skin  &  mucous  
3. S.A.B.E.   membranes  
4. Acute  myocardial  infarction   Hands   Cold   Warm  
5. Shock   Effect  of   Improves   No  improvement  
6. Panhypopituitarism   warming  
7. Acute  haemorrhage   the  hand  
8. Nephrotic  syndrome   Effect  of  𝑶𝟐   Improves   Slight  improvement  
Paroxysmal  pallor   inhalation  
1. Meniere's  disease  
2. Pheochromocytoma  
Effect  of   ↓   ↑  
exertion  
3. Migraine   Clubbing   Absent   Usually  present  
  TB   Conc.  of   Normal   Abnormal  (↓  Pa  O! ,  O!  
  1. Nutritional  anaemia   blood  gases   saturation)  
  2. Recurrent  hemoptysis   Polycythem Absent   Present  
  3. Toxaemia   ia  
  4. Side  effects  of  anti-­‐TB  drugs  (INH)   C.  Differential  cyanosis   D.  Reverse  differential  cyanosis  
  Suppurative  lung  disease   • Cyanosis  usually  with   • Cyanosis  usually  with  clubbing  limited  
  1. Anorexia  causing  nutritional  anaemia   clubbing  limited  to  the   to  UL  only  sparing  the  feets  
Causes  in   2. Recurrent  haemoptysis  in  bronchiectasis   LL  only  sparing  the   • Causes:  
pulmonary   Bronchogenic  carcinoma   hands   *Transposition  of  great    
disease   1. Bone  marrow  infiltration   • Cause:        vessels  
2. Anorexia   *Patent  ductus     *Coarctation  of  the    
3. Recurrent  hemoptysis      arteriosus  (P.D.A.)          aorta  
Alveolar  haemorrhage  syndrome      with  reversed  shunt  
Due  to  haemoptysis   E.  Chemical  cyanosis  
2.  Cyanosis   • Met-­‐haemoglobinaemia:  Cyanosis  occurs  when  there  is  ≥  1.5  gm%  
  Bluish  discoloration  of  skin  &  mucous  membrane  due   of  met  hemoglobin.  Caused  by:  
  to  increased  percentage  of  reduced  haemoglobin  (≥5   1. Hereditary:  Due  to  
Definition   gm)  in  capillary  blood  or  presence  of  abnormal  Hb   o Presence  of  hemoglobin  M  
N.B.   No  cyanosis  with  sever  anaemia  (Hb<6gm)   o Deficiency  of  methaemoglobin  reductase  
  A. Central  cyanosis   2. Acquired  
  B. Peripheral  cyanosis   o Exposure  to  chemical  agents  (aniline  dyes,  chlorates,  
Types   C. Differential  cyanosis   nitrates,  nitrite)  
D. Reversed  differential  cyanosis   o Drugs  (acetalinide,  nitroglycerine,  phenacetin  
E. Chemical  cyanosis   primaquine)  
  • Sulph-­‐haemoglobinaemia:  Cyanosis  occurs  when  there  is  ≥  0.5  
A.  Central  cyanosis   gm%  of  sulph-­‐hemoglobin    
  • Lateral  edge  of  the  under  surface  of  the  tongue   o Caused  by:  Drugs  (sulphonamides)  
Sites   • Inner  surface  of  the  lip    
  3.  Clubbing  of  Fingers  
  Chest  causes     ↑  longitudinal  &  convexity  of  nail  due  to  hypertrophy  of  
  1. COPD  (V/Q  mismatch)   Definition   soft  tissue  of  nail  &  its  capillaries  due  to  either  toxaemia,  
  2. Interstitial  pulmonary  fibrosis  (diffusion  defect)   anoxaemia  or  both  
  3. Acute  pulmonary  oedema  (shunt)     (i)  C.V.S.  causes  
  4. Complicated  bronchiectasis     1. S.A.B.E.  (pale  clubbing)  
Causes   5. Acute  upper  airway  obstruction     2. Congenital  cyanotic  heart  disease  with  right  to  left  
6. Respiratory  centre  depression     shunt  (blue  clubbing)  
7. Severe  pneumonia  (shunt)     3. Infected  aortic  bypass  graft  (pale  clubbing)  
8. Acute  total  lung  collapse     4. Left  atrial  myxoma  (pale  clubbing)  
9. Acute  severe  asthma  (V/Q  mismatch)      
10. Pulmonary  A-­‐V  malformation  (shunt)     (ii)  Pulmonary  causes  
11. Massive  pulmonary  embolism  (perfusion  defect)     1. Chronic  suppurative  lung  disease  
    • Bronchiectasis  
Cardiac  causes     • Chronic  lung  abscess  
1. Congenital  cyanotic  heart  disease  with  right  to  left     • Infected  cystic  lung  
shunt     • Empyema  with  bronchopleural  fistula  
2. Advanced  congestive  heart  failure     2. Interstitial  pulmonary  fibrosis  (blue  clubbing)  
3. Pulmonary  hypertension     3. Bronchogenic  carcinoma  (pale  clubbing)  
    4. Benign  pleural  mesothelioma  (pale  clubbing)  
B.  Peripheral  cyanosis     5. Chronic  fibrocaseous  pulmonary  T.B  (pale  clubbing)  
  • Nail  bed     6. Pulmonary  A-­‐V  malformation  (blue  clubbing)  
Sites   • Outer  surface  of  lip      
• Tip  of  nose     (iii)  Gastrointestinal  causes  
• Ear  pinna    
1. Primary  biliary  cirrhosis  
 
  1. Cold  weather   2. Ulcerative  colitis  
Causes  
  2. Peripheral  vascular  disease  (Raynaud's  disease)   3. Crohn's  disease  
  3. Right  sided  heart  failure  (stasis)   4. Steatorrhea  
Causes   4. Venous  obstruction  (thrombosis)   5. Intestinal  T.B  
5. Peripheral  circulatory  failure  (shock)   6. Bilharzial  ontestinal  polyposis  
  7. Carcinoma  of  esophagus  or  colon  
 GENERAL  EXAMINATION  
 
(iv)  Occupational  clubbing   Causes  of  reversible  clubbing  
Limited  to  the  thumb  &  index  fingers  (shoe  maker)   1. Correction  of  pulmonary  A-­‐V  malformation  
(v)  Familial  clubbung  (Pachydermoperiostosis)   2. Resection  of  bronchogenic  carcinoma  
It  is  a  hereditary  form  of  HOA  (autosomal  dominant)   3. Resection  of  benign  pleural  mesothelioma  
characterized  by:   4. Treated  lung  abscess  
• Digital  clubbing   5. Resection  of  cervical  rib  
• Periosteal  new  bone  formation  (over  the  distal  ends    
of  long  bones)    
• Coarsening  of  facial  features  with  thickening,   Neck  Veins  Examination  
furrowing  &  oiliness  of  the  facial  &  forehead  skin   Clinical  value  of  jugular  venous  pulse  &  pressure:  
  • Inexpensive  &  non  invasive  assessment  of  CVP  &  
Causes  of   1. Cervical  rib   intravascular  volume  
unilateral   2. Pancoast  tumour   • Information  about  right  ventricular  function  
clubbing   3. Aortic  anneurysm   Differences  between  venous  &  arterial  pulsation  
  1st  Degreee     Venous     Arterial    
  • Obliteration  of  the  angle  of  lovibond     Position   Change  by   No  change  
  • Loss  of  angle  can  be  visualized  by:   changing  the  
  1. Looking  tangentially  to  detect  obliteration.   position  of  the  
  2. Resting  a  pencil  over  the  nail.   patient  
  o clear  window  present  (normal)   Effect  of   Engorged  with   No  effect  
  o clear  window  absent  (clubbing)   straining   dimnution  of  
  3. Schmroth's  sign  (window  sign)   pulsation  
  o disappearance  of  diamond  shaped   Visibility   Better  seen     Better  felt    
  window  on  juxtaposition  of  the  2    index   Waves   Wavy   1  wave  
Degree  of   finger   Site   Lateral  to   Medial  to  sternomastoid  
clubbing   o normally  present  when  the  terminal   sternomastoid  
phalanges  of  paired  digits    are  
Effect  of   Can  be   Cannot  be  obliterated  by  pressure  
juxtaposed  
obliteration   obliterated  by  
2nd  Degree     pressure  
(parrot  peak  appearance)  
Upper  level   Got  an  upper   No  upper  level  
↑  convexity  of  the  nail   level  
3rd  Degree     Abdomino-­‐    
(drum  stick  appearance)   Jugular   +ve   -­‐ve  
↑  tranverse  diameter  of  distal  phalanx   reflux  
4th  Degree   Causes  of  congested:  
• Any  degree  of  the  above  +  Hypertrophic   Non  pulsating  neck   Pulsating  neck  veins  
osteoarthropathy  (HPOA)   veins  
• HOA  =  thickening  of  the  distal  ends  of  long  bones   1. Superior  vena  cava   1. Early  right  sided  heart  failure  
specially  the  radius  &  ulna   obstruction   2. Tricuspid  valve  disease  
• Thickening  is  due  to  subperiosteal  new  bone   2. Late  constrictive   3. ↑  intrapericadial  pressure  
formation   pericarditis   4. ↑  intrathoracic  pressure  
• It  is  an  X-­‐ray  sign.  Diagnosed  by:   3. Advanced  right   5. ↑  intrabdominal  pressure  
o Plain  X-­‐ray  of  long  bones   sided  heart  failure   6. Over  transfusion  especially  in  
o Bone  scan   4. Very  full  vein  may   patitents  with  renal  failure  
  be  non  pulsating  
  1. Loss  of  the  angle  of  lovibond     At  angle  of  45°  above  the  horizontal  
  2. Floating  nails  (ballotability  of  nail  bed)     • At  this  angle  right  atrium  is  at  the  same  level  of  sternal  
  3. Abnormal  phalangeal  depth  ratio:     angle  of  Louis  (junction  of  manubrium  with  the  body  
Diagnostic   o DPD  (distal  phalangeal  depth)  /  IPD       of  sternum  opposite  the  2!"  rib)  
   (interphalangeal  depth)       • Centre  of  the  right  atrium  (in  which  venous  pressure  
o Normal  DPD/IPD  ratio  =  0.895     by  cinvention  is  zero)  is  approximately  5cm  below  the  
o Clubbing  patient  ≥  1.0     sternal  angle  of  Louis  
    Sit  upright  &  take  deep  inspiration  or  Stand  fully  
Differential  clubbing   Reverse  differential  clubbing     upright  
• Limited  to  LL  only  &   • Limited  to  to  UL  only  &  sparing  the   Piatient's   • Patients  with  sever  venous  congestion,  the  level  of  
sparing  the  hands   feets   position   venous  pulsation  may  still  remain  behind  the  angle  of  
• Cause:  patent  ductus   • Causes:   jaw  
arteriosus  (P.D.A.)  with   1. Transposition  of  great    vessels   • Sit  upright  &  take  deeep  inspiration  to  lower  the  
reversed  shunt     2. Coarctation  of  aorta   upper  column  of  jugular  venous  blood  into  full  view    
Pathogenesis  of  reversed  differential  clubbing   • Ask  patient  to  stand  fully  upright  if  the  level  of  venous  
1. Both  the  aorta  &  pulmonary  artery  arise  from  the  right  ventricle,   pulsation  still  remains  behind  the  angle  of  jaw  
often  in  association  with  VSD,  PDA,  pulmonary  hypertension.  
 
2. Oxygenated  blood  from  the  left  ventricle  enters  the  pulmonary  trunk   How  to  estimate  CVP?  
through  the  septum,  shunts  through  the  PDA  into  the  descending   Normal  CVP  =  3-­‐7  mmHg  or  7-­‐11  centimeter  water  
aorta,  &  eventually  flows  to  lower  extremities.   1. First  position  the  patient  to  get  a  good  view  of  internal  jugular  vein  &  
  its  oscillations  
3. Conversely  oxygen  de-­‐saturated  blood  from  the  right  ventricle   2.  
enters  the  ascending  aorta  &  brachiocephalic  vessels,  thereby   a) Identify  the  highest  point  of  pulsation  in  IJV  
reaching  the  upper  extremities   b) If  unable  to  see  pulsations  in  the  IJV,  look  for  the    in  the  EJV,  
  although  the  might  not  be  visible  here  
4. Hence  the  hands  will  be  cyanotic  &  clubbed  but  the  feet  are  normal   c) If  see  none,  use  the  point  above  which  the  EJV  appear  to  
collapse.  
 GENERAL  EXAMINATION  
 
  Kussmaul's  sign  
3. Measure  the  vertical  distance  from  the  sternal  angle  to  the  top  of  of   • Paradoxical  increase  in  JVP  that  occurs  during  inspiration  
jugular  venous  pulsations  or  the  top  of  the  column  of  jugular  venous   • JVP  normally  decrease  during  inspiration  because  of  inspiratory  fall  
blood  in  centimeters   in  intrathoracic  pressure  and  its  sucking  effect  on  venous  return  
a) Place  your  ruler  vertical  on  the  sternal  angle   • Thus,  Kussmaul's  sign  is  a  true  physiologic  paradox  
b) Place  a  card  /  rectangular  object  at  an  exact  right    angle  to  the   Causes  of  +ve  Kussmaul's  sign  
ruler  (so  that  the  lower  edge  rests  at    the  top  of  the  jugular   Mostly  disease  that  interfere  with  right  ventricular  filling  as:  
pulsations)   1. Constrictive  pericarditis  
c) Read  the  vertical  distance  on  the  ruler   1. Pericardial  tamponade  
d) This  distance  represents  the  jugular  venous  pressure  (JVP)   2. Severe  right  sided  heart  failure  
e) CVP  is  5cm  more  than  JVP.  Thus,  CVP  =  JVP  +  5     3. Restrictive  cardiomyopathy  
  4. Tricuspid  stenosis  
4. When  there  is  severe  congestion  &  the  upper  column  of  jugular   5. Superior  vena  cava  syndrome  
venous  blood  or  pulsations  cant  be  seen  even  on  sitting  or  standing   6. Right  ventricular  infarction  
a) Ask  patient  to  raise  the  arm  in  straight  position  (veins  in  the    
dorsum  of  the  hand  is  engorged  from    systemic  congestion)    
b) Then,  ask  him  to  elevate  the  arm  slowly  until  the  veins  in  the    
dorsum  of  hand  become  collapsed.  
c) The  level  at  which  the  veins  collapse  can  then  be  related  to  
the  angle  of  Louis  &  the  CVP  is  measured  

 
Abdominojugular  Reflux  
• Previously  described  as  hepatojugular  reflux  
• Relies  on  observing  the  JVP  before,  during  &  after  compression  
of  the  abdomen  
  • Pressure  applied  over  the  abdomen  shifts  blood  into  
  the  thorax  &  right  atrium.  
Mechanism   • If  the  right  ventricle  is  unable  to  handle  this  
increased  load,  the  result  is  a  sustained  increased  in  
JVP  
Technique  of  Abdominojugular  Reflux  
1. Postion  the  patient  at  an  angle  of  45°  for  the  the  patient's  trunk  
usually  sufficient  so  that  the  jugular  venous  pulsations  are  properly  
monitored    
 
2. Periumbilical  compression  by  the  gently  rested  hand  with  widely  
spread  fingers.  Once  the  patient  is  well  relaxed,  gradual  &  
progressive  pressure  reach  a  steady  level  of  20-­‐35  mmHg.  The  level  
can  be  confirmed  by  placing  an  unrolled  bladder  of  adult  blood  
pressure  cuff  (partially  inflated  with  6  full  bulb  compression)  
between  the  examiner's  hand  &  the  patient's  abdomen.  
 
3. Throughout  the  maneuver  (before,  during,  after  compression),  
observe  the  column  of  blood  in  IJV  &  EJV.  
 
4. Abdominojugular  reflux  is  considered  positive  when  the  sustained  
increased  in  JVP  is  ≥  4  cm.  Conversely,  it  is  considered  negative  
(normal)  when  any  of  the  following  occurs:  
 
I. No  change  in  JVP  
II. Sustained  increased  in  JVP  ≤  3  cm  during  abdominal  
compression  
III. Transient  increase  in  JVP  at  the  beginning  of    abdominal  
compression  &  returns  to  normal  during  the  remaining  10  
seconds  of  abdominal  compression  
  Reflects  the  inability  of  the  right  heart  chambers  
  to  handle  an  increased  venous  return.  
  Positive  in:  
  1. Subclinical  right  ventricular  failure  
  2. Tricuspid  regurgitation  
Value  of   3. Tricuspid  stenosis  
abdominojugular   4. Constrictive  pericarditis  
reflux  test   5. Pericardial  tamponade  
6. IVC  obstruction  
7. Hypervolemia