Examine this patient's neck.

Examine this patient's cardiovascular system.



· Dyspnoea.

· Symptoms of right heart failure (leg oedema, ascites).


· The JVP is raised ... cm above the angle of Louis (manubriosternal angle). Remember that the JVP

may be raised to the level of the ear lobes.

· Comment on the waveform (timing it with the carotid pulse): - 'v' Waves of tricuspid regurgitation.

-Cannon waves of heart block.

-Absent 'a' waves in atrial fibrillation (irregular carotid pulse).

-Large 'a' waves of pulmonary hypertension, pulmonary stenosis, tricuspid


· Check the hepatojugular reflex.

· Tell the examiner that you would like to look for other signs of heart failure: -Basal crackles and

pleural effusion. -Dependent oedema (ankle and sacral oedema). -Tender hepatomegaly.


This patient has raised jugular venous pulse with 'v' waves (lesion) due to tricuspid regurgitation and is in

heart failure (functional status).


What are the causes of a raised JVP?

· Congestive cardiac failure.

· CDr pulmonale.

· Tricuspid regurgitation (prominent 'v' waves).

· Tricuspid stenosis (prominent 'a' waves).

· Complete heart block (cannon waves).

· Non-pulsatile neck veins seen in superior venal caval obstruction (see pp 5934).

How do you differentiate jugular venous pulsations from carotid

artery pulsations? Unlike the arterial pulse, the venous pulse has a definite upper level which falls

during inspiration and changes with posture. The venous pulse is seen to have a dominant inward motion,

towards the midline (the 'y' descent), whereas l~he arterial pulse exhibits a dominant outward wave. The

venous pulse is better seen than felt, whereas the arterial pulse is readily felt by very slight pressure of

the clinician's finger.

What do you know about the hepatojugular reflux?

A positive hepatojugular (abdominojugular) reflux is a feature of left ventricular systolic failure with

secondary pulmonary hypertension. [t is elicited by upper abdominal compression for -10 seconds. An

abnormal response is one wher there is an increase followed by an abrupt fall. The hepatojugular

manoeuvre is often useful in eliciting venous pulsations when they are not readily visible.


What do you know about the waveforms in the jugular pulse?

There are two outward-moving waves (the a and v wave) and two inward-moving waves (the x and y


· The 'a' wave is caused by atrial contraction and is presystolic. It can be identified by simultaneous

auscultation of the heart and the examination of the jugular venous pulse. The 'a' wave occurs at about

the first heart sound.

· The 'c' wave is due to closure of the tricuspid valve and is not readily visible.

· The 'v' wave results from venous return to the right heart (not due to ventricular contraction) and occurs

nearer to the second heart sound.

· The 'x' descent is due to atrial relaxation (sometimes referred to as systolic collapse).

· The 'y' descent is produced by opening of the tricuspid valve and rapid inflow of blood into the right


What is Kussmaul's sign?

Normally there is an inspiratory decrease in JVP. In constrictive pericarditis there is an inspiratory

increase in JVP. Kussmaul's sign is also seen in severe right heart failure regardless of aetiology. It is

caused by the inability of the heart to accept the increase in right ventricular volume without a marked

increase in the filling pressure.

Adolf Kussmaul (1822-1902) was Professor of Medicine successively at Heidelberg, Enlargen, Freiburg

and Strasbourg, and coined the term 'polyarteritis nodosa' (Ber/ Klin Wochnschr 1873; 10: 433).

Kussmaul breathing is deep sighing respiration seen when the arterial pH is Iow.