miss anything else. Are you guys happy?
What do you do in the full abdomen exam, does
that stuff include JVP?
You can do. What would you do when you examine
Position the patient to 45 degrees and turn
the head to the left and get a good light
source and feel the veins.
Absolutely. What’s the other thing you can
do to make --
Press on the liver. Exactly! So you just
make sure in that as
well that you’re asking them, are you
tender at all and I’m going to push in your
tummy. So the salient point for an abdomen
exam is make sure you’re exposing the patient
appropriately. Make sure that the patient
is lying flat. I remember in one exam that
a friend did at different university. They
had the patient at 45 degrees inclining and you had
to go in and put the patient flat. The other
thing is when you palpate in the abdomen,
make sure that you’re on the patient’s
level and you’re looking at the patient’s face.
Just be really systematic, okay? Just
make it look like you’ve done it a million
times before. So for shifting dullness,
you start at the
umbilicus? So you start at the umbilicus
and you go down.
You’re trying to demonstrate. So if you
imagine you’ve got fluid, it’s going to
sit in the flanks. So you’re going from
resonant, resonant, resonant into the fluid
level. That’s where it becomes dull. So you keep
your finger on that and get the patient
to roll over to the side.
Far away from you.
Well, yeah, they’d have to roll away from
you. So if you want them to roll towards you,
you percuss the other side over the patient.
Roll towards you, wait for 30 seconds, and
then re-percuss. So what additional information
reflex give you? In terms of the JVP, if you
think about the
blood supply going back to the heart, you
have a lot of venous reserve in the liver.
So when you’re pushing on that, you’re
increasing the venous return. So the idea
being that you might make a JVP that’s otherwise
not visible to be more prominent.
What would that be, normal or abnormal?
It’s in the context of the patient. So say
if you’re the patient that had a heart condition,
that might not result in any rise in the JVP.
But if you’ve got a patient that’s dehydrated
and you’re able to increase the venous return
to the heart, you might see that that’s
raised, so in dehydrated patient that would
cause a rise. It shouldn’t cause a rise in
a normal patient?
It will do. But if someone has got an incompetent
valve no matter how much blood you’re pushing
back into the heart, the amount, the cardiac
output is not going to be affected by whatever you effort is.
Does that make sense? I don't understand.
It doesn’t make sense
at all. Okay. So your cardiac output
is your stroke
volume. So the volume of blood that’s in
your ventricle times by your heart rate.
So when you’re looking at the JVP, you’re
not necessarily getting the patient’s heart
to work any faster but you are trying
to increase the amount of blood that’s going
back in. If you’ve got an incompetent valve,
so every time the ventricle beats it opens
up, but it is not closing and stopping the
blood from flowing back. You might get a lot
of blood coming up, but it would drop very
quickly. Does that make sense to you? Do you
necessarily see the JVP rising in the
It makes sense but now it doesn’t make sense
why you do it and do the reflex in the abdo
exam because if you can’t see it and then
you push on the abdomen and you can see it,
what’s the significance of that? Is it actually
raised or you’re just showing that it can
be raised by you pushing on this?
It can give you an idea about the patient’s
fluid status. And if you think that someone
has got a lot of hepatomegaly because it’s
now either you got a lot of venous storage
of blood. That might give you an idea that
the liver is enlarged as well. It’s not
directly related to an abdo exam which is
why I don’t always do when I do my abdo exam.
So in a normal person, when you press on the
abdomen, it wouldn’t raise as much?
If you have someone that is otherwise normal,
you push on the liver, the JVP will go up.
Okay. If you’ve got a patient with dehydration,
you might not see the JVP to begin with and
you push on the liver, it might go up a little
bit, because you’re increasing that cardiac
return to the heart. So you’ve got an increased
volume that’s coming out of the ventricles.
If you’ve got a patient that is otherwise,
what was the other question?
Normal. Yeah. If a patient is otherwise
you do that, you will get a rise but it’s just
demonstrating that perhaps if you couldn’t
see it first, you are doing something to make
it more prominent. I hope that makes sense.
Yeah, I understand it to be a way of making
it more easy to say rather than any pathological --
It’s all in the clinical context
you’re examining the patient. So don’t
get too hung up about it.