Vancouver IM LMR

Thanks Dr Reynolds!

Here is a summary of physical exam findings in aortic regurgitation, characterization of the JVP and interpretation of abnormal JVP waveforms

Aortic regurgitation

AR – Stanford Medicine 25

The murmur – decrescendo early-diastolic blowing murmur, best heard on the left lower sternal border (around 3-4th intercostal space) produced by the regurgitant blood jet after the aortic valve “closes”

**Improve yield by sitting the patient upright, leaning forward, and in full expiration (brings heart forward to chest wall)

**Murmur increased with isometric hand grip to increase afterload and increase regurgitant flow.

May be accompanied by Austin Flint murmur (functional mitral stenosis 2/2 AR jet preventing the anterior leaflet of the MV fully opening – producing a mid to late diastolic murmur.

Other findings caused by a widened pulse pressure (increased SBP due to compensatory increased stroke volume + decreased DBP due to retrograde flow)

Examples:

• Corrigan’s pulse (bounding carotid pulse with rapid diastolic collapse)
• Water hammer pulse detected by lifting the patient’s arm and palpating at radial/ulnar/brachial arteries
• MANY other signs where pulsation is detected as a consequence of the wide pulse pressure (Quincke’s capillary pulse, head bob (De Musset), uvula pulsation (Muller’s), retinal artery pulsation (Becker) etc – see the article

Jugular venous pulsation

Neck vein exam – Stanford Medicine 25

• JVP vs carotid
  • JVP is biphasic vs carotid monophasic
  • JVP changes with position (sinks when you raise head of the bed)
  • JVP changes with respiration (decreases with inspiration)
  • JVP is non-palpable
  • JVP will increase with RUQ pressure
• Features to report:
  • The height above sternal angle (at 30 degrees)
  • The waveform
  • Response to abdominal pressure (positive abdominojugular/hepatojugular finding is a JVP that remains increased over >4cm after 10 seconds of abdominal pressure – a normal response would be transient increase of the JVP with pressure (increased preload) and then decrease as the RV appropriately processes the bolus)

• Jugular venous waveform components:
  • A wave due to atrial contraction
  • C wave due to ventricular contraction with tricuspid bulging back into RA (you won’t see this clinically)
  • X descent due to atrial relaxation
  • V wave due to atrial venous filling
  • Y descent after the tricuspid opens and the ventricles fill
• Abnormalities in jugular venous waveform:
  • Large a wave
    • Resistance to right atrial emptying (eg tricuspid stenosis, pulmonary hypertension)
    • Atrium contracts against a closed tricuspid eg AV dissociation (third degree heart block, VTach)
  • No a wave – no atrial contraction – atrial fibrillation
  • Elevated v wave
    • Resistance to atrial filling eg due to the backward jet of tricuspid regurgitation
  • Absent v wave -> “the patient is dead”