32 Questions
What is the primary purpose of face assessment in physical examination?
To identify distress, anxiety, and state of mind
What is the normal position of the trachea during breathing?
In the midline
What is the significance of tracheal deviation?
It is a sign of unequal pressure on either side of the thorax or neck
What is the normal appearance of the internal jugular vein in the supine position?
It is visibly distended with blood
What is Kussmaul's Sign?
A paradoxical increase in JVD during inspiration
What happens to the column of blood in the internal jugular vein when the bed is elevated to >45°?
It falls to about 3-4 cm above the sternum
When should the assessment of JVD be made?
At the end of exhalation
What is the normal classification of JVD in the supine position?
Normal
What is the significance of a gross tracheal deviation?
It is an abnormal sign
What is the primary characteristic of apneustic breathing pattern?
A pattern of irregular breathing with tonic inspiratory cramps and periods of apnea
What does a paradoxical increase in JVP during inspiration indicate?
Reduced right ventricular filling
What is the primary cause of cor pulmonale?
Lung disease
What is the normal response of JVP during spontaneous inspiration?
It decreases
What is the primary indicator of venous hypertension?
Elevated JVP
What is the primary cause of a slight tracheal deviation?
Unknown causes
What is the primary purpose of assessing JVP?
To assess the level of pressure in the venous system
What is the primary purpose of applying firm hand pressure over the abdomen during the abdominojugular reflux test?
To increase venous return to the vena cava
Why is it recommended to position the patient semi-recumbent during the assessment of JVP?
To increase the accuracy of the measurement
What is the significance of a positive abdominojugular reflux test?
It indicates right heart failure
What is the recommended duration of pressure application during the abdominojugular reflux test?
10 seconds to 1 minute
What is the primary effect of applying pressure over the abdomen during the abdominojugular reflux test?
It pushes blood into the vena cava
Why is it necessary to observe the JVP during quiet breathing?
To establish a baseline JVP
What is the recommended pressure to be applied over the upper middle quadrant of the abdomen during the abdominojugular reflux test?
30-40 mmHg
What is the primary reason to avoid directly pressing over the liver during the abdominojugular reflux test?
It may cause discomfort in the patient
What happens to the JVP in some normal subjects during the HJR maneuver?
It decreases for several seconds
What is the significance of a positive HJR test?
It indicates a right ventricle that can't handle increased blood volume
What is the position of the patient during the JVD test?
Almost upright with the head elevated to 45 degrees
What is the normal response of the JVP in a normal heart?
It rises and then returns to normal
What is the significance of a right ventricle that can't handle increased blood volume?
It is a sign of right ventricular failure
What is the position of the patient during the HJR test?
Supine with the head elevated to 45 degrees
What is a common abnormality that produces a positive HJR test?
Tricuspid regurgitation
What is the significance of an elevated JVP that stays elevated for more than 3 cm?
It is a sign of right ventricular failure
Study Notes
Heart Failure and Jugular Venous Pressure
- In a normal heart, the JVP rises for several seconds but then returns to normal.
- In some normal subjects, the HJR maneuver may decrease the JVP for several seconds due to reduced venous return.
Abnormal Conditions
- In abnormal conditions, the heart is unable to increase its output, and the JVP rises >3 cm and stays elevated.
- Common abnormalities that produce a positive HJR test include:
- Tricuspid regurgitation
- Heart failure due to other non-valve failure causes
- Constrictive pericarditis
- Right ventricular infarction
- Restrictive cardiomyopathy
- Pulmonary hypertension and right heart failure
HJR Test
- The HJR test is performed with the patient supine but the head elevated to 45 degrees.
- Abdominojugular reflux (or HJR) is an abnormal distension of the neck veins seen when firm hand pressure is applied over the abdomen.
- Pressing directly over the liver may cause discomfort, so instead, the physician may ask the patient to hold their breath or perform a Valsalva maneuver.
Performing the HJR Test
- The patient is positioned supine with the head elevated to 45 degrees (semi-recumbent).
- Observe the height of the blood column and pulsations in the right jugular veins during quiet breathing.
- Press with about 30-40 mmHg on the upper middle quadrant (center of the abdomen) for 10 seconds to 1 minute.
- If the JVP level increases >3 cm above the baseline and remains elevated for >10 seconds, the HJR test is positive (+).
Physiology of the HJR Test
- Pressure on the abdomen increases venous return to the vena cava and the right atrium.
- A normal (competent) heart quickly increases cardiac output to compensate for the increased venous return.
Physical Examination
Face and Neck
- Face assessment helps identify distress, anxiety, LOC, state of mind, and oxygenation.
- Look for nasal flaring, pursed lip breathing, and cyanosis of the lips and tongue.
- Neck assessment to determine trachea position:
- Normally the trachea remains in the midline during breathing.
- Gently palpate the thyroid cartilage to assess tracheal deviation.
Neck Vein Assessment
- Neck vein assessment indicates right atrial pressure:
- In normal subjects, the internal jugular vein is visibly distended with blood (JVD) in the supine position.
- When the bed is elevated to >45°, the column of blood normally falls to about 3-4 cm above the sternum.
- JVD should decrease during spontaneous inspiration.
- A paradoxical increase in JVD during inspiration is called Kussmaul's sign.
Learn how to assess the face and neck to identify signs of distress, anxiety, and oxygenation. This quiz covers nasal flaring, pursed lip breathing, cyanosis, tracheal deviation, and neck vein assessment.
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