Friday, 9 February 2007

JVP and the ECG

I have been unable to update my blog these last few days as I have been trying to get the new Microsoft Windows Vista to work properly. Having finally succeeded I have been able to update my blog today.

I want to mention something about the Jugular Venous Pulse (JVP) or Distension as the termed is coined elsewhere.

This physical sign is often missed or not even appreciated and through my daily teaching, the junior doctors are now looking for the JVP, and in some cases, it has proven a great diagnostic sign especially with the added help of an ECG (shin-densu).

The JVP is an estimate of the pressure of the venous circulation. It can be raised by many processes but particularly heart failure and atrial fibrillation.

The JVP should only be read with the patient at an incline of 45 degrees and not flat. Hence, you need to sit your patients up, and if they have severe cardiac or respiratory disease, they should be sat up already!

The JVP is measured vertically from the manubriosternal joint (sternal angle) to the top of the JVP wave in centimetres with the head turned to the left and with the physician examining from the traditional right side of the patient. A normal JVP <4cm.

A JVP should be seen as the superficial vein becomes distended over the sternocleidomastoid muscle area. It has a double pulse for every arterial (carotid) pulse. On sitting the patient vertically, unless the problem is very severe, the JVP should disappear. Also, on pressing the liver, the JVP should be seen to rise (Hepatojugular reflex-- I almost never do this as it can be painful and restrict breathing). I also occlude the jugular vein from below upwards thereby allowing me to differentiate whether the raised pressure is truly from the heart or whether it is simply due to filling from the cranial venous circulation.

The JVP has two waves, the first due to blood regurgitating during atrial contraction as it empties into the ventricle and the second as the atrium refills with blood before the ventricle relaxes and the tricuspid valve still remains closed. These are termed as 'a' and 'v' waves respectively.

Hence, the JVP can be predominantly raised with the 'a' wave or the 'v' wave but for the beginner, just seeing if the JVP is generally raised is the important thing.

JVP should be assessed in all patients and it should give a diagnostic clue in conditions such as CHF, large pulmonary embolism, atrial fibrillation, valvular disease, COPD and other chronic respiratory diseases.

A clue as to the cause of the raised JVP can be sometimes seen on the ECG.

For example, today I saw an elderly lady with COPD. Before seeing her I reviewed her ECG which showed peak / tall 'p' waves consistent with the term p pulmonale and hence, right atrial enlargement. Her arterial blood gas revealed a respiratory alkalosis and profound hypoxaemia of 55mmHg. Examination of her JVP revealed large venous waves (the rapid upstroke and rapid down stroke of the venous blood consistent with Tricuspid Regurgitation). She had no obvious right ventricular heave and no murmur as it is likely she has complete TR. She had no peripheral oedema.

The history of smoking, the profound hypoxaemia, ECG changes of the 'p' wave led me to conclude that she had developed Type 1 Respiratory Failure and chronic pulmonary vascular vasoconstriction had caused RA enlargement and TR. This would be consistent with Cor Pulmonale.

Sometimes the ECG will show RV strain (ST depression and T wave inversion) in the RV leads e.g. V1, V2, V3, aVR and with the presence of p pulmonale, hypoxaemia one should also consider pulmonary embolism although other diagnoses such as pulmonic stenosis, mitral stenosis, primary pulmonary hypertension, cardiomyopathy should also be considered amongst others.

Finally, examples of predominant 'a' wave elevations in the JVP include: pulmonary hypertension, pulmonary stenosis.

Large 'a' (Cannon) waves are seen in complete heart block, atrial flutter, single ventricle pacing, ventricular arrhythmias/ectopics.

Absent 'a' waves in atrial fibrillation (no proper atrial contractions!)

Large systolic 'v' waves are seen in Tricuspid Regurgitation.

JVP can be raised for other reasons such as fluid overload, cardiac tamponade, SVC obstruction, constrictive pericarditis.

Good hunting for the JVP!!!

Tuesday, 6 February 2007

History and Physical Quiz: I need your Answers!!!!

Today I am going to do something different. I am setting you all a quiz!

I will give you a short history and show you the physical signs that I picked up on this patient and please send me your answers to the questions I have posed at the end of this blog.


This is a 41 year old male computer worker who developed bloody diarrhoea of up to 10 times per day. The diarrhoea was non-painful and he experienced no abdominal pain. He had these symptoms for 2 months prior to coming to the hospital.

He had recently developed a fever prior to admission and in fact, that was the reason for him seeking medical intervention on this occasion. He denied any shivers or shakes. He noticed the skin on his legs had become discoloured but they were not painful.

He had no chest pain, dyspnoea, cough, sputum or haemoptysis. No genitourinary, joint, throat, or cranial symptoms.

He denied eating raw or poorly cooked foods and he denied any foreign travel. He had no pets at home. He had a similar episode of this in the recent past and was taking some medication but he could not remember the name of his diagnosis or treatment when he was admitted to hospital.

He had no recent weight loss, night sweats or loss of appetite. He was taking no anti-coagulant drugs or Non-Steroidal Anti-Inflammatory Drugs. He denied any previous peptic ulcer disease and he drank no alcohol. He had experienced no haematemesis and had no symptoms of gostroesophageal reflux disease (GERD).

There was no family history of bowel disease or cancer.

On examination: He looked relatively well. BP and Pulse were stable. Temp 38.0 degrees C. Resp Rate 14/min and O2 sat 98% on room air.

No Jaundice, Anaemia, Clubbing, Cyanosis, Oedema, Lymphadeopathy (No JACCOL)

CVS: pulse 80/min, regular. BP 120/80 mmHg. JVP was not raised. Heart sounds 1 + 2. No added sounds or murmurs. No evidence of DVT in the lower extremities.

RESP: Trachea central. No tracheal tug. Expansion normal bilaterally. Percussion resonant throughout and Auscaultation revealed Vesicular breath sounds.

ABDO: Soft, non-distended, non-tender, no organomegally. Bowel sounds normal. No signs of chronic liver disease. Rectal examination: fresh red blood, no obvious discharging fistula orifices.

JOINTS: Normal range of movement. Non-tender and no swelling.

EYES: See Photograph

SKIN: See Photograph


Question 1:

What is the eye sign?

Question 2:

What is the lower extremity skin signs and what are the possible causes of it?

Question 3:

With the history and examination in mind, what is the likely diagnosis or at least, provide some differential diagnoses?

Question 4:

What investigations should be done e.g. radiological / microbiological, etc...?

Question 5:

What treatments should be commenced on admission for this patient?

I will publish all answers and I will provide you the answers in one week from today!!

Good Luck!!!

Monday, 5 February 2007

Nails-- The Looking Glass Into The Body

Splinter Haemorrhages

Good day to you all and I must say what glorious sunny weather we are now having this month-- only February and I have already seen trees producing blossom! That is global warming!

As for Nails, well these are something that are almost entirely missed out from the physical examination findings , as nails are simply not looked at by most junior doctors.

I sometimes take a long time looking at nails, as they can sometimes give the diagnosis!

For example, Splinter Haemorrhages can signify endocarditis (more than 6 are significant). Clubbing can lead the physician to look for one of the many causes of this physical finding.

Moreover, finding Beau's Lines (a horizontal depression / line across the nail signifying nail growth arrest) can semi-quantitively date the time of the onset of the illness. The nails of the hand growth at 0.1mm/day = 1mm per 10 days. Hence, measuring from the line to the nail fold in millimetres and multiplying by 10 will provide the period of onset of the illness in days.

Nails can reveal the cause of a rare form of arthritis and a relatively common skin condition which include psoriatic arthritis and psoriasis respectively. For example, a patient may have a substantial thickening of the nail bed (subungual hyperkeratosis), the nail may become weak and break off from the nail bed (onycholysis), the nail may have many longitudinal lines and small 'pits' in the nail like a thimble used for sowing, so-called Nail Pitting.

Nails can reveal Aortic Regurgitation via Quinke's sign-- the in-out movement of blood in the interface between the white and pink areas of the nail due to the raised pulse pressure associated with this condition. It is quite rare to see it, but I have seen it 3 times in my career!!

Nail changes may also be seen in some inherited diseases such as the Polyendocrine Deficiency, Yellow Nail Syndrome etc....

Hence checking the nails can be a very important thing to do.

Clubbing-- should never be forgotten, but the causes cover many different systems.

Clubbing of a Patient's Fingers with Fibrotic Lung Disease


  • Infective: Infective Endocarditis
  • Genetic/Developmental : Cyanotic Heart Disease
  • Cancer: Atrial Myxoma
  • Infective: TB, Empyema, Lung Abscess, Pneumonia, Bronchiectasis
  • Cancer: Primary Lung Cancer, Mesothelioma
  • Inflammatory: Fibrosing Alveolitis / CFA
  • Genetic: Cystic Fibrosis (from repeated suppurative chest infections)
  • Inflammatory: Crohn's Disease, Ulcerative Colitis
  • Malignancy: Lymphoma
  • Metabolic: Chronic Liver Disease
  • Malabsorptive: Coeliac Disease
Also Remember:

FAMILIAL (a friend of mine has congenital clubbing!!)

  • Axillary artery aneurysm
  • Brachial arterio-venous malformations

Clubbing of a Patient's Toes!!

My Normal Finger

Normal 'diamond-shape' when both index fingers are put together as mirror images. The diamond is normally produced but this diappears with Clubbing.