Fig. 2B.25: Examination of height of JVP.

Fig. 2B.26: Image showing engorged neck veins.

Causes of Raised JVP

Engorged (Fig. 2B.26) and pulsatile neck vein Engorged and nonpulsatile neck vein

Cardiac causes Superior mediastinal syndrome

Valsalva maneuver

Chronic constrictive pericarditis (advanced stage) Right heart failure

Congestive cardiac failure

Chronic constrictive pericarditis

Cardiac tamponade

Complete heart block

Restrictive cardiomyopathy

Superior vena cava (SVC) obstruction

Tricuspid stenosis

Noncardiac causes

Pulmonary thromboembolism

Pulmonary hypertension

Acute nephritis

Pregnancy

Fluid overload status

•

•

•

•

•

•

Waveforms of JVP:

Component Cardiac event responsible

A wave Atrial contraction/systole

X wave (initial x descent) Atrial relaxation

C wave Closure of the tricuspid valve (some consider c wave is due to the impact of carotid pulsation)

X’ wave (X descent following

“C” wave)

Downward movement of the floor of the right atrium while the right ventricle contracts (called

the ‘descent of the base’)

V wave Atrial filling during ventricular systole

Y wave RA emptying during ventricular diastole

H wave (Hirschfelder wave) Seen in diastasis

“a” wave (most prominent of JVP)

Absent Atrial fibrillation

Large/giant “a” wave

Tricuspid stenosis (TS)

Tricuspid atresia (TA)

Right atrium (RA) myxomas

Right ventricular (RV) infarct

RV cardiomyopathy

Pulmonary hypertension (PH)

Pulmonary stenosis (PS)

Pulmonary embolism (PE)

Aortic stenosis (AS)*

Hypertrophic cardiomyopathy (HCM)* (Bernheim effect*)

Cannon “A” waves

Regular Junctional rhythm

Ventricular tachycardia (VT) (1:1 retrograde conduction)

Irregular Complete heart block (CHB)

Atrioventricular (AV) dissociation

Ventricular ectopics

Ventricular tachycardia

V pacing

*Bernheim effect: Left-sided diseases causing prominent a wave, (ie) severe LVH with septal

thickening interfere with RV filling resulting in prominent a wave.

“v” wave

Diminished Cause of diminished v wave is hypovolemia

Prominent Tricuspid regurgitation (TR)*

Atrial septal defect (ASD)

Ventricular septal defect (VSD), Gerbode defect—abnormal shunting between the left ventricle and the right

atrium due to either a congenital defect or prior cardiac insults

Congestive heart failure (CHF)

Atrial fibrillation

Cor pulmonale

*In TR due to absent X and prominent V wave merging with C wave, it results in large positive systolic

and regurgitant waves (CV wave) followed by a rapid deep ‘y’ descent. This may cause subtle motion of

earlobe with each heart beat (The LANCISI’s sign)

Fig. 2B.27: Jugular venous pulse demonstration.

Fig. 2B.28: Jugular venous wave pattern JVP components and waveforms (Fig. 2B.27).

‘X’ descent (systolic collapse)

Absent Tricuspid regurgitation

Prominent Tamponade

Atrial septal defect (ASD)

Pericarditis—constrictive

•

‘Y’ descent (diastolic collapse)

Slow descent Tamponade

Tricuspid stenosis (TS)

Right atrial (RA) myxoma

Rapid descent Constrictive pericarditis

Severe tricuspid regurgitation (TR)

Severe right ventricular (RV) failure

Differences between Constrictive Pericarditis and Cardiac Tamponade (Fig. 2B.29)

X wave Y wave

Pericarditis—constrictive + ++ (prominent Y)

Tamponade ++ (prominent X) --

TR -- ++

(Mnemonic: Prominent Y and X waves can be remembered with mnemonic PaY TaX)

Fig. 2B.29: Waveforms of JVP in tamponade versus constrictive pericarditis.

OTHER SITES OF JVP ESTIMATION

Gaertner’s Method

Normally, the superficial veins of dorsum of hand collapse when raised above the sternal angle.

Persistent prominence is suggestive of raised central venous pressure (anthem sign—when the same

is tested by asking the patient to make a fist and raise the arm like an anthem pledge).

May’s Sign

Visible engorged vein on the undersurface of tongue in sitting posture.

ABDOMINOJUGULAR (AJR) REFLUX OF RUNDOTT (PREVIOUSLY KNOWN

AS HEPATOJUGULAR REFLUX)

Demonstration (Fig. 2B.30)

The patient is placed in a 45° semirecumbent position and firm, consistent abdominal pressure 40 mm

Hg is applied, preferably over the right hypochondrium (an inflated BP cuff may be used).

•

•

–

•

–

•

–

•

•

•

•

Historically pressure was applied for 15 seconds; however, recent studies suggest 10 seconds is

adequate

Fig. 2B.30: Demonstration of abdominojugular reflux.

Normal response:

Transient rise of around 4 cm for about 4–5 cardiac cycles (approximately 5 sec)

Sustained response/positive response:

Earliest sign of right heart failure (RHF), also seen in tricuspid regurgitation (TR)

Absent response/negative response:

Obstruction/thrombosis of inferior vena cava (IVC) or hepatic veins as seen in Budd-Chiari

syndrome.

Friederick’s Sign of Constrictive Pericarditis

Friederick’s sign describes a rapid fall and rise in the JVP. It occurs when stiff ventricles are unable to

accommodate the rapid ventricular filling that should follow opening of the tricuspid valve in the

presence of elevated atrial pressure.

Square Root Sign of JVP

Dip and plateau pattern of JVP seen in constrictive pericarditis.

Kussmaul Sign of JVP

Normally when the patient inspires there is fall in the height of JVP due to increased negative

intrathoracic pressure.

Kussmaul sign is the paradoxical elevation of JVP during inspiration.

Seen in:

Constrictive pericarditis

Severe heart failure

Right ventricular infarction

Restrictive cardiomyopathy.

M pattern in JVP

Constrictive pericarditis Due to prominent x and y waves

■

■

■

■

■

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

ASD Due to prominent A and V waves

Raised jugular venous pressure with shock

Congestive heart failure

Cardiac tamponade

Right ventricular infarction

Tension pneumothorax

Massive pulmonary embolism

BODY TEMPERATURE

Core Body Temperature

It usually refers to the temperature of the internal body core, measured under the tongue, in the ear

canal or in the rectum.

Normal range (oral): 36.8 ± 0.4°C (98.2 ± 0.7°F)

Regulation of temperature: Under the control of neurons of preoptic anterior hypothalamus and

posterior hypothalamus.

Site of Examination of Temperature

Oral temperature Probe placed under the tongue into the sublingual pockets and the lips closed around the

instrument

The patient should not have recently smoked or ingested cold or hot food or drink

Usually tested for about 3 minutes

Oral temperature reflects changes in core body temperature through the branch of the external

carotid artery which perfuses the posterior sublingual pockets

Rectal readings are 0.4–0.6°C

higher than oral recordings

Measured with a lubricated blunt-tipped glass thermometer inserted 4– 5 cm (2.5 cm in

children) into the anal canal at an angle 20° from the horizontal with the patient lying prone

Usually tested for about 3 minute

Lags behind changes at other core sites as it is located far from the central nervous system

as well as from the pulmonary artery

Indicates the deep visceral temperature. Can be affected by the temperature of the skin of the

buttocks, the iliac artery and iliac vein

Tympanic temperature The scanning tip should be gently placed in the ear canal and then slowly inserted against

the tympanic membrane snugly

Measures the infrared heat waves from the tympanic membrane

Close to hypothalamus and rapid measurement of core body temperature

Axillary readings lag behind

oral temperature by 0.1–0.2°C

Thermometer placed in the axilla and shoulder adducted

Convenient for patient

Core temperature cannot be assessed directly

Lags behind the changes in core body temperature

Temporal (forehead) measurement

Placed on the skin of the forehead

An electronic thermometer that is fast and accurate

Less invasive than the tympanic thermometer and more reliable when used correctly

•

•

•

•

•

Thermometers (Fig. 2B.31)

Glass thermometer and electric digital thermometer

Glass thermometer bulbs contain an alloy called galinstan.

Electric digital thermometers are more convenient than glass instruments because the probe cover is

disposable, response time is quicker (allowing accurate measurements within 10–20 seconds), and

there is a signal when the rate of change in temperature becomes insignificant.

The most common methods of temperature assessment that carry the least amount of risk for patient

injury are the use of glass or electronic digital thermometers to measure oral, rectal, axillary, or vaginal

temperatures; basal thermometers; temporal artery thermometers; tympanic thermometers; and liquid

crystal forehead temperature strips. These methods can be utilized in healthcare settings and also

within the patient’s home.

Although the more invasive methods are more accurate, they carry a higher risk of potential

complications, so they are not routinely utilized in areas outside of a critical care or surgical setting.

Examples of invasive methods of temperature assessment are esophageal and rectal temperature

probes, temperature-sensing indwelling urinary catheters, temperature-sensing pulmonary artery (PA)

catheters, a cardiopulmonary bypass (CPB) machine, and extracorporeal membrane oxygenation

(ECMO).

Fig. 2B.31: Thermometer showing marking in both Celsius and Fahrenheit.

Circadian Variation of Temperature

Circadian rhythm is governed by suprachiasmatic nuclei in anterior hypothalamus.

Normal variation is 0.5–1.0°C over the day

Lowest temperature is noted at 6:00 am and peaks at 4:00–6:00 pm.

Variation of Temperature during Menstrual Cycles

An abrupt increase of 0.3–0.5 °C accompanies ovulation and may be useful as a fertility guide.

Fever

Fever is an elevation of body temperature that exceeds the normal daily variation and occurs in

conjunction with an increase in the hypothalamic set point.

It can be defined as temperature of >37.2°C (98.9°F) at 6 am or >37.7°C (99.9°F) at 4–6 pm. When the hypothalamic set point is raised, the body is perceived to be cooler than the new set point.

Shivering is initiated to generate heat. Blood is shunted from the periphery to the core to conserve heat

and sweating is diminished. The generated heat will raise the body temperature to match the elevated

set point. When the hypothalamic set point is lowered, either as part of the normal diurnal fluctuations

that occur during an infection or in response to antipyretic agents, heat is lost by evaporation (sweating)

and radiation (cutaneous vasodilation).

Types of fever based on duration

Acute fevers <7 days Infectious diseases such as malaria and viral-related upper respiratory tract

infections

Subacute

fevers

Usually not more than

2 weeks in duration

Typhoid fever and intra-abdominal abscess

1.

2.

Chronic or

persistent

fevers

>2 weeks duration Chronic bacterial infections such as tuberculosis, viral infections like human

immunodeficiency virus (HIV), cancers and connective tissue diseases

Grading of Fever based on Body Temperature

Body temperature °C °F

Normal 37–38 98.6–100.4

Mild/low grade fever 38.1–39 100.5–102.2

Moderate grade fever 39.1–40 102.2–104.0

High grade fever 40.1–41.1 104.1–106.0

Hyperpyrexia >41.1 >106.0

The conversion formula is:

T°F = 9/5 (T°C) + 32

T°C = 5/9 (T°F) – 32

Patterns of fever (Fig. 2B.32)

Type of

fever

Description Seen in

Continuous

or

sustained

fever

Defined as fever that does not fluctuate more than about

1°C (1.5°F) during 24 hours, but does not touch the

baseline

Lobar and gram-negative pneumonia, typhoid, and

acute bacterial meningitis

Remittent

fever

Defined as fever with daily fluctuations exceeding 2°C

but does not touch the baseline

Remittent fevers are often associated with infectious

diseases such as infective endocarditis, rickettsia

infections, and brucellosis

Intermittent

fever

Defined as fever present only for several hours during

the day

Malaria, pyogenic infections, tuberculosis (TB),

schistosomiasis, lymphomas, leptospira, Borrelia, Kalaazar, or septicemia

Double quotidian fever (12 hours periodicity) Kala-azar, gonococcal endocarditis. Adult-onset Still’s

disease

Quotidian fever (periodicity of 24 hours) Mixed falciparum and vivax

Tertian fever (periodicity of 48 hours) Plasmodium falciparum, ovale and vivax

Quartan fever (periodicity of 72 hours) Plasmodium malariae

Pel-Ebstein’s fever (intermittent low-grade fever

characterized by 3–10 days of fever with subsequent

afebrile periods of 3–10 days)

It is thought to be a typical but rare manifestation of

Hodgkin’s lymphoma

Relapsing

fevers

Refer to those that are recurring and separated by

periods with low-grade fever or no fever

Seen in malaria, lymphoma, Borrelia, cyclic

neutropenia, and rat-bite fever

•

•

•

•

Fig. 2B.32: Clinical pattern of fevers.

Fever with Night Sweats

It has been described in infectious diseases such as TB, Nocardia, brucellosis, liver or lung abscess,

and subacute infective endocarditis, as well as in noninfectious diseases such as polyarteritis nodosa

and cancers such as lymphomas.

Fever with Bradycardia

It is a feature of untreated typhoid, leishmaniasis, brucellosis, Legionnaire’s disease and psittacosis, and

yellow fever.

Fever with Unknown Origin

In 1961, pyrexia of unknown origin (PUO) was originally defined by Petersdorf and Beeson as an illness

of more than 3 weeks duration, fever higher than 38.3°C (101°F) on several occasions and diagnosis

uncertain after 1 week of study in hospital.

This definition has been modified, removing the requirement that the evaluation must take place in

the hospital and refined to include four different subgroups, each requiring different investigative

strategies: classical, nosocomial, neutropenic, and human immunodeficiency virus (HIV)-related.

Hyperpyrexia

(Body temperature >105°F)

Causes Include:

Pontine hemorrhage

Rheumatic fever

Meningococcal meningitis

Cerebral malaria

•

•

•

•

•

•

•

•

•

•

•

•

•