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The Rational Clinical Examination
David L. Simel, Drummond Rennie
Abnormal Central Venous Pressure
Deborah J. Cook, David L. Simel
Distinguishing Arterial (Carotid) From Venous (Jugular) Pulsation

Topics Discussed: abdominojugular reflex test, central venous pressure, measurement of, central venous pressure-biological function, diagnostic process, jugular venous pulse, paradoxical inspiratory filling of neck veins, vein of neck

Excerpt: "The right internal jugular vein should be used to assess CVP for several reasons. It is in direct line with the right atrium, thereby favoring unimpeded transmission of atrial pulsations and pressure. Clinical assessment of CVP on the left may be marginally higher than that on the right. Finally, constricted or tortuous external jugular veins may introduce inaccuracy. Proper positioning is crucial for examination of the neck veins. The patient's head is supported to relax the neck muscles, and the trunk is inclined at an angle that brings the top of the column of blood in the internal jugular vein to a level above the clavicle but below the angle of the jaw; in normal subjects, this positioning is accomplished at 30 to 45 degrees above the horizontal. In patients with elevated venous pressure, it often is necessary to elevate the trunk beyond 45 degrees, and patients with severe venous congestion may have to stand up and inspire deeply to bring the meniscus down into view. In some cases, the level of venous pulsation will be seen behind the angle of the jaw or will appear to move the earlobes. If the pressure in the internal jugular vein is high, venous pulsations will be lost in the completely full vein, and the high venous pressure may be overlooked...."
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