Term
| Jugular venous pulse is used as a diagnostic tool in the cardiac exam because it correlates with what structures in the heart? |
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Definition
Right Atrium and Right Ventricle (Pressure) |
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Term
| A skilled 2nd year medical student who volunteered for SACHS clinic helped interview a 34-year old male. During the physical exam, they observed a normal jugular venous pulse. What did they see? |
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Definition
While listening to the patient's heart beat and observing the Right Internal Jugular Vein, the med student saw an outward deflection ('a' wave) prior to S1 followed by an inward deflection ('x' descent). Then saw a smaller outward deflection at S2 and a subsequent inward deflection ('y' descent). |
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Term
At what body position can the venous pulse waveforms be adequately observed?
A. Supine
B. Standing
C. Reclined
D. Sitting hunched with the chin tucked
E. All of the above |
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Definition
C. Lying at an angle (slight recline)
This is done to expose the internal jugular pulsation so while looking a patient face-to-face the anterior neck is easily visible. |
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Term
| Why does the 'a' waveform occur on a venous pulse? |
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Definition
Atrial contraction creates a slight backflow up the internal jugular vein due to the pressure created by contraction/resistance of ventricle. |
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Term
| With what part of an ECG does the 'a' waveform of the jugular venous pulse correlate? |
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Definition
The P wave (atrial electrical stimulation) on an ECG immediately preceeds the 'a' waveform |
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Term
The 'a' wave lies between:
A. Diastole --> Systole
B. Systole --> Diastole |
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Definition
A. Diastole --> Systole
Because it occurs due to atrial contraction, it will occur at the tail end of diastole and be "presystolic in timing" |
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Term
| Why do we disregard the 'c' wave on regular physical exams? And what can be done to measure the 'c' wave that is not normally done during a standard physical examination? |
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Definition
The 'c' wave is too small to be visible during a regular exam. However, it can be observed on the descent of the 'a' wave just after S1 by inserting a catheter into the right internal jugular vein. |
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Term
| The bulging of the tricuspid valve caused by RV contraction provides the pressure that creates which wave in the JVP? |
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Definition
'c' wave
(not normally visible in physical exam) |
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Term
The easiest JVP waveform to identify is:
A. 'a' wave
B. 'c' wave
C. 'x' descent
D. 'v' wave
E. 'y' descent |
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Definition
C. 'x' descent
The inward motion of the SCM occurs during ventricular systole. It occurs at the same time as the carotid pulse. |
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Term
| Why does the 'v' wave occur? |
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Definition
A build up of venous return to the right atrium occurs when the RV is in isovolumetric relaxation (tricuspid valve is closed). |
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Term
| When the tricuspid valve opens and right atrial pressure falls, what visibly occurs with the SCM (internal jugular vein)? |
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Definition
The SCM shows a slight inward motion ('y' descent). |
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Term
A JVP waveform reveals normal timing, but abnormally large 'a' waves. This could be caused by which of the following (more than one possible)?
A. Tricuspid stenosis
B. Inferior Vena Cava Occlusion
C. Pulmonic hypertension
D. Right-to-Left Shunt in the Abdominal Aorta
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Definition
A & C
Tricuspid/Pulmonary stenosis, pulmonary hypertension, and RV hypertrophy are all common causes of "Giant 'a' waves" due to the increased resistance during atrial contraction. |
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Term
| While observing the JVP waveforms a 1st year med student notices about every 5 or 6 seconds what they think might be an abnormally large outward motion. After observing for 30 seconds, the student realizes this intermittent outward motion occurs simultaneously with the carotid pulse. What abnormality are they observing? |
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Definition
Cannon 'a' waves occur when RA contraction is simultaneous with ventricular contraction. The closed tricuspid valve sends the force of the contraction upward into the jugular veins. |
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Term
| Intermittent cannon 'a' waves were observed in an 84 year old man who had a surgical history that included a double bypass surgery and one other additional cardiac surgery. What is most likely the 2nd cardiac procedure? |
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Definition
Implantation of a right ventricular demand pacemaker. |
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Term
A 78 year old woman presents with lightheadedness during light/moderate exertion. After the initial exam the resident identifies decreased cardiac output as a potential reason for the lightheadedness.
What JVP waveform abnormality that an ECG could confirm would make the resident think that there was decreased cardiac output? |
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Definition
Atrial Fibrillation (A-Fib) can lead to the cessation of atrial contraction and occurs more prominently in older patients. The results can lead to decreased cardiac output due to decreased filling capabilities.
The 'a' wave is absent.
- In some patients a-fib can go unnoticed and not be a serious problem. |
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Term
| A patient with complete (3rd degree) heart block should have what type of arterial pulse and JVP waveforms? |
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Definition
3rd degree heart block is usually accompanied by a regular arterial pulse and intermittent cannon 'a' waves. |
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Term
| Atrioventricular dissociation with an irregular arterial pulse can indicate the presence of what heart condition? |
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Definition
Premature ventricular contractions
(which can lead to tachycardia and ventricular fibrillation) |
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Term
| Why are giant 'v' waves also called 'r' waves? |
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Definition
The 'r' stands for regurgiation and the giant 'v' wave occurs because during RV contraction, there is tricuspid regurgitation. |
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Term
Which of the following JVP waveforms DO NOT occur with the Carotid Pulse?
A. Cannon 'a' waves
B. 'x' descent
C. Giant 'v' waves
D. Giant 'a' waves |
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Definition
D. Giant 'a' waves
- occur due to increased resistance during atrial contraction (RV diastole)
-All the other waveforms occur during ventricular systole |
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Term
| While observing a 4-year old in the Children's Hospital, a 3rd year medical student noticed a pulsation or bulging of the eyeballs and ear lobes. What heart condition could this child be experiencing? |
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Definition
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Term
| A slow 'y' descent is associated with what heart condition? |
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Definition
Tricuspid stenosis
(obstruction to RA emptying) |
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Term
| A rapid y descent occurs in someone with TB because of what correlative heart condition? |
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Definition
Constructive pericarditis
- calcified pericardium leads to a prominent diastolic collapse of the venous pulse |
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Term
| What JVP observation do constrictive pericarditis, restrictive cardiomyopathy, RV failure/infarction, and tricuspid stenosis have in common? |
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Definition
Kussmaul's sign (increase in JVP) occurs when the right heart cannot accommodate increased venous return during inspiration. |
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Term
| The Abdominojugular Test (AJT) is done by pressing on the mid-abdomen with firm pressure for 10 seconds. What subsequent JVP observation would indicate a positive test result? |
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Definition
A sustained rise of 4 cm in the height of the JVP for as long as the pressure is applied to the abdomen would indicate a positive result. Negative results show an initial spike in JVP, but show a return to normal after a few seconds. |
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Term
| What does a positive AJT indicate? |
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Definition
Inability of the right heart to handle increased venous return (RV infarction/hypertrophy, tricuspid regurgitation, constrictive pericarditis). |
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Term
| Decreased compliance of the venous system occurs during some isolated acute left-sided heart failure when atrial pressure exceeds 15 mm Hg. What would be the expected result of a AJT test? |
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Definition
Positive due to increased blood to the poorly compliant venous system. |
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Term
| What is the primary differential for a positive AJT test? |
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Definition
Pulmonary stenosis or hypertension are the primary differential for a positive AJT. Tricuspid regurg/stenosis and RV infarction/hypertrophy are secondary. |
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Term
| When ankle edema is not accompanied by a positive AJT, what are the most likely causes? |
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Definition
Drugs (calcium channel blockers), low albumin (liver failure/nephrotic syndrome), venous or lymphatic obstruction (low fluid return) |
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Term
| What common misconception could be inferred from the so-named apical impulse in regards to its cause? |
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Definition
The apical impulse is not consistently related to the anatomic apex of the heart, but is produced by anterior and counter-clockwise motion of the anteroseptal wall of the LV against the inner chest wall. |
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Term
| In what position should the patient be in to assess the apical impulse? |
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Definition
supine and in the left lateral decubitus position |
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Term
| Describe the normal apical impulse in relation to size, location, duration, and contour: |
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Definition
Size: about a dime
Location: confined to a single intercostal space (most commonly the 5th) medial to the midclavicular line
Duration: begins with 1st heart sound, prior to carotid pulsation
Contour: moves outward during the first 3rd of systole
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Term
| A pressure over-loaded ventricle will result in hypertrophy. What is the main change from a normal apical impulse that would indicate this condition? |
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Definition
- sustained (prolonged) apical impulse
Also...
-size no more than 3 cm
- similar confinement (1-2 intercostal spaces)
- similar location (potentially a little more lateral)
- occurs with carotid pulsation
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Term
Match the heart accommodation to the heart condition:
A. LV hypertrophy
B. LV dilation
1. Aortic stenosis
2. Aortic Regurgitation
3. Pressure over-loading
4. Volume over-loading |
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Definition
A. 1. Aortic Stenosis, 3. Pressure over-loading
B. 2. Aortic Regurgitation, 4. Volume over-loading
- LV hypertrophy occurs in response to increased pressure during systole
- LV dilation occurs due to increased stroke volume caused by regurgitation of blood |
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Term
| Describe the apical impulse for someone with a volume over-loaded LV in relation to size, location, force, duration, and contour: |
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Definition
Size: larger than normal (4-5 cm)
Location: displaced down and to the patient's left (if its to the left of the midclavicular line it is a strong indicator for increased LV end-diastolic volume)
Force: hyperdynamic (increased amplitude and force)
- it is difficult to get rid of with applied pressure
Duration: Fairly normal duration and timing
Contour: More of a spike than normal |
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Term
| While performing a normal breast exam on a 38 year old single mom, her physician noticed a strong thrust to the left of the midclavicular line just beneath the breast. What condition could this indicate? |
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Definition
This could indicate a volume over-loaded LV due to an aortic or mitral regurgitation. |
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Term
| When examining a patient in the left lateral decubitis position, what modifications would a medical student need to make to their palpation and interpretation of the apical impulse? |
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Definition
- the location is unreliable
(usually displaced laterally 1-5 cm)
- sustained apical impulse still indicates ventricular hypertrophy
- a large apical impulse (> 4 cm) indicates a dilated LV |
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Term
| A pressure overloaded right ventricle can produce an outward impulse at what location? |
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Definition
Just to the left of the sternum
(occurs simultaneous with apical impulse) |
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Term
| A hyperdynamic, high amplitude impulse along the left sternal border and beneath the xiphoid process could indicate what? |
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Definition
A volume over-loaded RV
(pulmonic or tricuspid insufficiency, Atrial Septal Defect) |
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Term
| What part of the hand is best when trying to identify impulses and individual heart sounds? |
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Definition
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