JVD and dyspnea, lung percussion

[Toast Fairy]

I have 2 questions regarding the physical exam.

I have heard you (Dr. Mansoor) say a few times that looking at the JVP is crucial in evaluating a patient with dyspnea. I have always associated jugular venous distention with right heart failure, restrictive cmp, constrictive pericarditis and tamponade but all of those seem, to me atleast to be less common than simple left heart failure where symptoms like orthopnea, bendopnea, paroxysmal nocturnal dysuria etc seem more helpfull to me than looking at the JVP. Am I missing something in my approach to dyspnea and the JVP?

The second question would be regarding to lung percussion. I can appreaciate asymetrical findings very well, I have the most problems when I have a symetrical finding in the basal regions of the lungs. Is there a consensus on the topography of the lung bases when looking at the back? In other words how would one orient himself and assess how low in the back should the lungs normally reach? I tried it with counting the spinous processes and the ribs but both seem to take up way too much time and to me feel unreliable.

Any thoughts or inputs are appreaciated! 🙂

[André Mansoor]

Hey TF great to hear from you. I’ll address each question below:

1. You are right. The jugular venous pulse (including the jugular venous pressure, or JVP) is a reflection of the right heart. However, the most common cause of right-sided heart failure is left-sided heart failure. The pressure and strain the LV experiences when it is failing will eventually back up and begin to affect the RV. So patients with decompensated left-sided HF will typically have the symptoms and signs that you describe (orthopnea, PND, S3, etc.) as well as elevated JVP. Each of these symptoms and signs is valuable when it comes to the overall assessment of the patient.

2. The exact location of the lung/hemidiaphragm interface can vary from patient to patient. The lungs will be resonant to percussion while the hemidiaphragms will be dull. Normally the right hemidiaphragm is about 1-2 cm above the left. One thing you can do to be sure you are percussing the hemidiaphragm is to identify diaphragmatic excursion. To do this, have the patient breathe all the way out and hold it. Percuss down the back until the note changes from resonant to dull. Mark that spot. Next, have the patient breath all the way in and hold it. Repeat the percussion and mark the spot where the note changes. It should move down the chest between expiration and inspiration, the result of the hemidiaphragm moving down with inspiration. This will tell you for certain that you have identified the hemidiaphragm.

Hope this helps !

[Toast Fairy]

Greetings Dr. Mansoor! It’s always a pleasure to hear from you!

Thank you for the thorough answers! With your help I have become very comfortable with the quantitative assesment of the JVP, I am working on my qualitative wave assesment skills. I am also working on my lung percussion and as I said when a patient for example has a small left and a rightsided pleural effusion I find it hard to appreciate the pathology on percussion, I’ll try to identify the hemidiaphragm with your method regularly. Practice makes the master! Also as I am currently studying in Graz the home of Dr. Auenbrugger It would be a shame not to gain some more percussion skills 🙂

• This reply was modified 2 years, 8 months ago by Toast Fairy.

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