l M ed ici ne

An Insider's Guide
to Clinica se en in ~ a l ~
al de la y ca n be

•
Ri gh t ra di o- fe m or
•
ao rti c ste no s1 s.
--------
RESPIRATION
e er th e p .
R es pi ra to ry R.at th e ex am in er 's pa lmofovth e ab datie llt's
fa ll
un te d by pl a~ 1n g th e ri se an d, • b ea
0 1lle
n.
Co . te nt io n y rn 8
s at
ab do m en , no tin .g er t th e pa tie nt d (F"1g. 2B .I 7) llz-i ng
ou s l Y d iv ot he r ha n •
ne
Si m ul ta. , ls e w ith yo ur
th e pa tie nt s pu ,.,
r

.
dorsal is pedis artery
tra tion of palpation of
fig . 28.15: Demons

m ul ta ne ou sl y to
th ra di al pu ls es si
ce ed to pa lp at e bo g. Th is is kn ow n as ra
di o- ra di al
ua lit y in tim in
te ct an y in eq
e:
elay. Ca us es in cl ud
Pr es ub da vi an co ar ct at io n
l rib
sy nd ro m e: Ce rv ica
• Th or ac ic in le t sp ira to ry rate.
as e
• Takayasu's di se Fig. 28 .1 7: M et ho
d of ca lcu lat ing re
c ar ch an eu ry sm
• Ao rti = 4: 1
tic us sy nd ro m e : re sp ira to ry ra te
• Sc al en us an
su bd av ia n <!_rtery No rm al pu ls e ra te
ht
• An om al ou s rig
• A be rr an t co ur se
of ra di al ar le cy 14·h11H tl t¥ l· & ,, :;;. Br ad yp ne a < 1O
Tachypnea >2 0 CNS-depressant
el ay (Fig. 28 .1 6) dr ug s (e.g., opiate
s,
R ad io -f em or al D re ac h th e ra di al
Physiological:
e ta ke n fo r th e pu lse wave to e Anxiety benzodiaz ep ine s,
No rm al ly th e tim ise co nd s an d fo r th
af te r th e ca rd ia c sy sto le is 80 m ill or al pu ls e is Exertion ba rb itu ra te s,
ar te ry . If th e fe m
is 75 m ill es ec on ds or al Pa ological:
th alc oh ol)
fe m or al ar te ry it ls e it is ca lle d as ra di o- fe m Emphysema Ur em ia
ye d co m pa re d to ra di al pu
de la Pneumothorax Inc re as ed
t th e de la ye d distress fro m
delay. io n of ao rta . It is no Acute respiratory int ra cr an ial pressu
re
co ar ct at
Th is is a gg n of ad a slo w ra te of infections a
ls e wa ve bu t in ste Hy po th er mi
th e fe m or al pu
arrival of Pleurisy Hy po th yr oid ism
ak . e lis m
ris e to a de la ye d pe iv e di se as e of th Pulmonary em bo
ca n ra re ly be se en w ith oc cl us ili ac ar ter ies ~e ta bo lic ac ido sis
Th is or ex te rn al
ao rta , co m m on iliac Cardiac ins uff ici en
cy
bi fu rc at io n of th e
Anemia
lik e ao rto ar te rit is.
Hy pe rth yro idi sm
ira tor y mu sc les
Weakness of re sp
Obesity
ll disease
Restrictive chest wa

ra tio n
Muscles o f R es pi
ssive
Main: Pr ed om in an tly pa
l muse! pr oc es s
f~ te rn al intercosta e
• Diap hr ag m
(used in
Accessory muscles
: Ac ce ss or y m us cl es
:
Serratus an te rio r forceful expiration)
id (SCM) In te rn al int er co sta
ls
Sj!?rnocleidomasto-
Scalenus an te rio r
Ab do m in al mu sc les
• Pectoralis • Qu -;d r:; tu s lu
mborum
femoral delay. Trapezius iss im us do rs i- ___.,.
ns tra tio n of radio- _l at
Fig. 28 .1 6: De mo
 General Examination

Condition Description
Type of Respiration
Normal breathing rate and pattern
Keep two hands flat, one on the chest and other on the abdomen [VV\f\1\/\] Eupnea
and watch for movements of hand (Fig. 28.18). Increased respiratory rate
In abdominothoracic-movements of hand over the abdomen [ VU\MMf\M I Tachypnea
Decreased respiratory rate
are more prominent. [ ~ ) Bradypnea
Absence of breathing
In thoracoabdominal-movements of hand over the thorax [ I Apnea
are more prominent.
Normal rate, but deep respirations
Abdominothoracic Thoracoabdominal [VV\/V\] Hyperpnea
Due to well-developed Well-formed internal Gradual increases and decreases in
abdominal muscles intercostal muscles l ~ l Cheyne-
Stokes
respirations w1ffiperiods of apnea
Seen in males Seen in females asps)
Ra
ILMLN I Biot's wit set~

IWN'INW'MI Kussmaul's Tachypnea and hyperpnea

Prolonged inspiratory phase with
[m##m1M1] Apneustic sfiorfenea exp,rafory pnase
Fig. 2B.19: Different type of breathing patterns.

Pursed Lip Breathing

• Seen with ~hronic obstructive pulmonary diseas.e
(COPD)
• Mechanism of auto-positive end-expiratory pressure
(PEEP)
• The purpose of this breathing is to slow down the air
flow during the exhalation to build up back pressure in
the airway to avoid a sudden drop in intrapulmonary
pressure resulting in alveolar and airway collapse.
Fig. 2B.18: Method of assessing type of respiration.

Variants Airway Obstruction

Purely thoracic • Upper airway obstruction-prolonged inspiration
Abdominal movement Thoracic movement during • Lower airway obstruction-prolonged expiration.
during respirations is absent respiration is absent
Peritonitis Pleuritic chest pain
Pregnancy Defective chest wall
BLOOD PRESSURE
Ascites/ovarian cyst Respiratory muscle paralysis Definition
[neurogenic, neuromuscular
junction (NMJ), and muscular] Arterial blood pressure (BP) can be defined as the lateral
pressure exerted by the moving column of blood on the walls
Abnormal Patterns of Breathing (Fig. 28.19) of the arteries.
Regular Irregular BP = Cardiac output x Peripheral resistance
Cheyne-Stokes (periods Biot breathing (an uncommon
Systolic blood pressure (SBP) Diastolic blood pressure (DBP)
of apnea alternating with variant of Cheyne-Stokes
hyperapnea) Defined as the maximum Defined as the minimum
respiration. Periods of apnea
Cardiac failure (LVF)-most BP in the arteries attainable pressure that is obtained at
alternate irregularly with a
common cause during systole the end of the ventricular
series of breaths of equal depth
Raised intracranial pressure that terminates abruptly) diastole
(ICP) Meningitis Normal: 120 + 20 mm Hg Normal range: 60-90 mm Hg
Brainstem lesions Pulse pressure (PP) Mean arterial pressure (MAP)
Kussmaul's (rapid deep Ataxic Denotes the difference DBP + one-third pulse
breathing) Brainstem disorders between systolic and pressure
Metabolic acidosis [diabetic Apneustic diastolic pressure
ketoacidosis (OKA) and renal Pontine lesions PP = SBP - DBP = 40 mm Normal = 95 mm Hg
failure] Hg
 An Insid er's Guid e to Clini cal Med
icine
Kor otk off Sou nds The five phas es of bloo d pres
sure mea sure men t via aus -........
Pres sure >BP
Systolic bloo d t20m mH g Phase 1: A thud cuit-'tl()11 ,
_
... 15~o~m.;.;.:.::m
.- .!..: :...:.H.:.&-_.r_1_2o_m_m_H,-=g~~~~~~~-7-orm:..:.:m.:...:
pres sure (SBP) ...:H.12.g___,,........:o~n
ttOm mH g Phase 2: A blow ing nois e rnrn Ii

Phase 3: A softe r thud

i
too mm Hg

90m mHg Phase 4: A disa ppea ring

blow ing nois e (muf fling ) Phas e 2 Phas e 2 Phas e 3 Phas e 4
t-- --4 --- 7- --- --+ ---
Phase 5: No Koro tkoff
-j_ _P _h as e 5
Diastolic blood 80 mm Hg Fain t tapp ing Swis hing Loud knoc king
pressure (OBP ) soun ds Muffed

Types and Cha rac ter of Kor otk

off Sou nds
AHA 2017 clas sific ation

Systolic BP
Dias tolic BP
Norm al <12 0mm Hg And <80 mm Hg
Elevated 120 -129 mm Hg And <80 mm Hg
Stage 1 hypertension 130-139 mm Hg Or 80-8 9mm Hg
Stage 2 hypertension ~14 0mm Hg
Or \
N
"."":o-i-e:-=E~sc=-g-u-:-id-;-e-:li:--n-es:-:2:::0::-18:::-=-:an::-:d;-c:::o:-=m::-: ~90 mm Hg
:p:-:a:;ri::so:n:-:t:ab~l:e:of-;J;;:N;;C:-:7;-:a:n:d~A:-;:H~A;-:2::-;0::1:;7-:a:re:-
:d:;:-is::-:c:-:u-=-:ss-e-;-d-:--in-A:--n-n-e-xu_r_e_s__ __
_....::__ _ _ _ _ _ ______ \

Key steps
.\
Specific instr uctio ns
Step 1: Properly The pati ent should rest com forta bly
prepare the patient for 5 minutes prio r to the measure l
back supported. The patient's legs ment in the seated position with th
should be uncrossed with feet flat • \
The pati ent should avoid caffeine, on the floo r (Fig. 28.20)
exercise, and smoking for at least 30 e,r \
Ensure that the pati ent has emp tied minutes before measurement
his/her bladder
Neit her the pati ent nor the observer
should talk before or duri ng the mea
Measurements made whil e the pati surement
ent is sitting or lying on an examining
Step 2: Use prop er
table do not fulfi ll these criteria
Use a BP mea sure men t device that
technique for BP has been validated, and ensure that
The arm sho uld be bare, supp orte the device is calibrated periodically
measurements d and kept at heart level
Position the mid dle of the cuff on
the patient's upper arrn at the leve
the ster num ) (Fig. 28.2 1) l of the righ t atriu m (the midpoint of
Use a cuff with an app ropr iate blad
der size: Bladder widt h should be clos
and leng th sho uld cover 80-100% e to 40% of the arm circumference
of the arm circumference. The lowe
abo ve the elbo w crease with the r edge of the cuff should sit 3 cm
bladder centered over the brachia!
Either the stethoscope diap hrag m artery
or bell may be used for auscultatory
readings
Step 3: Take the prop er At the first visit, record BP in both
arms. Use the arm that gives the high
measurements nee ded Repeat bloo d pressure measuremen er reading for subsequent readings
ts should be taken 1-2 minu tes apa
for diagnosis and Increase the pressure to 30 mm Hg rt
above the level at whic h the radia
trea tme nt Place the bell or diap hrag m of the l puls e is extinguished
stethoscope over the brachia! arte
of elev ated BP/ Ope n the con trol valve so that the ry
rate of defl atio n of the cuff is 2 mm
hyp erte nsio n Systolic bloo d pressure is the appe Hg per hea rt bea t
arance of the first Koro tkof f sound
The dias tolic bloo d pressure is the
poin t at whic h the sound disappea
If Koro tkof f sounds con tinu e as the rs (phase 5 Korotkoff)
level approaches O mm Hg, listen
to indi cate the diastolic bloo d pres for whe n the sound becomes muff
sure led
. Ste p 4: Prop erly Record BP to the closest 2 mm Hg
on the sphygmomanometer, as well
doc ume nt accu rate BP the pati ent (supine, sitti ng or stan as the arm used and the position of
ding )
read ings Not e the time of mos t recent BP med
icati on taken before measuremen
ts
• Step S: Average the Use an average of ~2 readings obta
ined on ~2 occasions to estimate
read ings In presence of atrial fibri llatio n, min the individual's level of BP
imu m of 3 BP readings have to be
estimated
Step 6: Provide BP Provide pati ents the SBP/DBP read
ings both verbally and in writ ing
read ings to pati ent
 General Examina tion

Fig. 2B.20: Demonstration of BP measurement.

Fig. 2B.21: Demonstration of placement of BP cuff.

Selection Criteria for BP Cuff Size for ausculta tory method . The auscult ory gap occurs when the
Measu remen t of BP in Adults first Korotkoff sound fades out for about 20-50 mm Hg only
to return. It can result in following erroneo us blood pressur e
.
'Arm circumference Usual cuff size
reading:
22-26cm Small adult 1. Undere stimatio n of systolic blood pressur e
27-34cm Adult 2. Overest imation of diastolic blood pressur e
35-44cm Large adult An auscult atory gap is commo n in elderly hyperte nsive
45-52 cm Adult thigh patients . It occurs in some hyperte nsive patient s only.
Auscult atory gaps are related to carotid atheros clerosis
and to increas ed arterial stiffness in hyperte nsive patients ,
indepen dent of age.

White Coat Hyper tensio n

'-'----C uff
Normal blood pressur e at home or on ambula tory blood
;-....,...- --Artery
pressur e monitor ing but elevate d office blood pressur e.

Masked Hyper tensio n

Elevate d blood pressur e at home or on ambula tory blood
~ . J - r - - - ~ Stethoscope pressur e monitor ing but normal office blood pressur e.

Paroxysmal Hyper tensio n

Episodic elevated BP.

200 mm Hg Pheochromocytoma
Panic disorders
18 +- SBP Labile hyperten sion
170
160 Carcinoid
Auscultatory
130 gap Clonidine withdraw al
120 Renovascular hyperten sion
+- Hypoglycemia
80 80 DBP Cheese reaction
40 Anxiety
Hyperthy roidism
Fig. 2B.22: Auscultatory gap. Coronary insufficiency
Cluster or migraine headaches
Auscultatory Gap (Fig. 28.22) Seizure disorder
An auscult atory gap also called as silent gap is the interval CNS lesions (such as stroke, tumor, hemorrhage)
Drugs-c ocaine, lysergic acid diethylamide, amphetamine
of pressur e where Korotkoff sounds indicati ng true systolic
Baroreflex failure
pressur e fade away and reappea r at a lower pressur e point
Factitious hypertension
during the manua l measur ement of blood pressur e by
r
Clinical Medicine
An Insider's Gulde to
Contd...
Pseudohypertension Chronic kidney disease Chronic hypovolerrr i ~ " - I
Hg hig11er
Defined as cuff diastolic blood pressure ~15 mmd ·essure. • Amylotdosls a frequent feature ; , •
than simultaneously measured intra-arterial bloo pr BP cuff Guillaln-Barre syndrome. autonomic failure l
A palpable although pulseless, radial artery while~I1~er sign. • Paraneoplastic autonomic exacerbates orth~s
neuropathy symptoms
is inflated above systolic pressure, is, a po~-~~~:of :rteries. • Famlllal dysautonomia (Riley-Day
Osler sign occurs due to Monckcberg s scle •
syndrome)
• Primary autonomic failure 1'
Paradoxical Hypertension
On starting treatn1ent with antihyper!~nsi·ves' the B ns
P . es (Bradbury-Eggleston syndrome)
'\
instead of falling in the following co nd itc°~E) 'nhibitors or Postprandial Hypotension ~\
1
1. Angiotensin-converting enzyme A) f patient with In postprandial hypotension, blood pressure falls oc \
angiotensin receptor blockers (ARBs or a
within one to two hours after a meal. ClJr:
renal artery stenosis . . ochromocytoma l
2. Beta-blockersgiventoapauentwitbph: . autonomic Nocturnal hypertension \
3. Beta-blockers in a patient wi th dia euc The definition of nocturnal hypertension is night-time Bp
neuropathy. 2::120/70 mm Hg(>ll0/65 mm Hg by the new2017 ACC/AfL\I
guidelines). Clinic and morning home BP of <130/80mmll i
Hypotension is defined as masked nocturnal hypertension and as maskJ l
Hypotension is defined as blood pressure that is lower than uncontrolled nocturnal hypertension under a medicated\
90/60mmHg. condition. The pattern of circadian rhythm of BP can b\•
Reference: NIH evaluated by ambulatory BP monitoring (ABPM). e
Cause of hypotension according to age group: In healthy subjects, night-time BP decreases by 10% to
Older adult
20% of daytime BP (normal dipper pattern). This circadian
Younger adult Any adult age group
Parkinson's
rhythm of BP is determined partly by the intrinsic rhythm 1i
Pregnancy Chronic liver disease
• Vasovagal syncope Diabetic autonomic disease of central and peripheral clock genes, which regulate the\
: Situational neuropathy Dysrhythmia neurohumoral factor and cardiovascular systems, and Partly •
syncope Secondary amyloidosis Micturition by the sleep-wake behavioral pattern.
Primary Addison's disease syncope
Hypertensive patients without organ damage also exhibit

________________
amyloidosis Hypopituitarism Carotid sinus
Primary Severe hypothyroidism syndrome the dipper pattern; however, those with organ damage tend to
autonomic failure Vitamin 812 exhibit nondipper patterns with diminished night-time BP fall

I
;,,._
deficien~--~ Night-time BP dipping patterns are classified into 4 groups:\
Postural Hypotension/Orthostatic Hypotension dipper, nondipper, riser, and extreme dipper patterns
(Fig. 2B 23).
• A drop in blood pressure (hypotension) due to a change in
body position (posture) when a person moves to a more Nighttime surge 1
Blood Morning surge
vertical position, i.e., from sitting to standing or from lying pressure ,-------, 1'
'OSA Cold
down to sitting or standing. Arousal Exercise I

• Postural (orthostatic) hypotension is diagnosed when, REM sleep ' Work-site stress
Nocturia Smoking
within 2-5 minutes of quiet standing (after a 5-minute Alcohol (dinner)
period of supine rest), one or both of the following is Insomnia
Sleep apnea
present:
At least a 20 mm Hg fall in systolic pressure
At least a 10 mm Hg fall in diastolic pressure Salt
Salt sensitivity
• Many disorders can cause orthostatic hypotension, with CKD
CHF
the two major mechanisms being autonomic failure, Diabetes
which can be caused by multiple disorders, and severe

-
Structural vascular
disease Basal BP Arising
volume depletion. Insomnia N1ghtt1rne (sleep)
Autonomic failure Volume depletion
Fig. 28.23: Nocturnal BP dipping patterns.
Diabetic neuropathy Acute or subacute
I Parkinson disease volume depletion Ambulatory BP Monitoring (ABPM)
I Dementia with Lewy bodies (due to diuretics,
hyperglycemia, Thresholds for hypertension diagnosis based on ABPM
MSA (Shy-Drager syndrome)
hemorrhage, or : 24-h average , ~130/80rnm
Splnal cord transection vomiting)
............. ...... . .
-· ,,.: :.---~. .
. .
i Awake (daytime} average • ~135/SSmm
Contd... ; _Asleep (night-time) average .. _. 12ono mil\
 General Examination

Clinical Indications for ABPM

Calculated ABI values should be recorded to 2 decimal
places.
Identifying White-coat hypertension phenomena
False resistant hypertension in treated subjects
Identifying masked hypertension phenomena Ultrasound device
Masked hypertension in untreated subjects
Masked uncontrolled hypertension in treated subjects
Identifying abnormal 24-h blood pressure patterns
• Daytime hypertension
• Siesta dipping/postprandial hypotension
• Nocturnal hypertension
• Dipping status
- Morning hypertension and morning blood pressure
surge
- Obstructive sleep apnea
- Increased blood pressure variability Blood pressure cuff
Assessment of treatment
Increased on-treatment blood pressure variability
Assessing 24-h blood pressure control
Identifying true resistant hypertension
Assessing hypertension in the elderly
Assessing hypertension in children and adolescents
Assessing hypertension in pregnancy
Assessing hypertension in high-risk patients
Identifying ambulatory hypotension
Identifying blood pressure patterns in Parkinson disease
Endocrine hypertension
Brachia! artery

ANKLE-BRACHIAL INDEX Fig. 28.24: Measurement of ankle brachia I index.

• The ankle-brachia! index (ABI) is the ratio of the systolic ABI value Interpretation
blood pressure (SBP) measured at the ankle to that
Greater than 1.4 Calcification/vessel hardening
measured at the brachial artery.
• Originally described by Winsor in 1950, this index was 1.0-1.4 Normal
initially proposed for the noninvasive diagnosis oflower- 0.9-1.0 Acceptable
extremity peripheral artery disease (PAD). 0.8-0.9 Mild arterial disease
• Later, it was shown that the ABI is an indicator of 0.5-0.8 , Moderate arterial disease
atherosclerosis at other vascular sites and can serve
as a prognostic marker for cardiovascular events and Less th an o.5 Severe arterial disease
~~:.nalimpairment, evenintheabsenceofsymptoms • JUGULAR VENOUS SYSTEM
• The ABI is performed by measuring the systolic blood Jugular Venous Pulse
pressure from both brachial arteries and from both the
It is defined as undulating top of oscillating column of blood
dorsalis pedis and posterior tibial arteries after the patient
in right internal jugular vein that faithfully represents the
has been at rest in the supine position for 10 minutes.
~ressure and volumetric changes in the right side of heart
• The systolic pressures are recorded with a handheld 5- or
which changes with various stages of cardiac. cycle and
10-mHz Doppler instrument (Fig. 2B.24).
respiration. '
• Calculating the ABI
An ABI is calculated for each leg. The ABI value is
Why is the Right IJV Preferred?
determined by taking the higher pressure of the 2
arteries at the ankle, divided by the brachia! arterial • Right side internal jugular vein (UV) is in direct
systolic pressure. In calculating the ABI, the higher of connection.
the two brachia! systolic pressure measurements is • Straight line course through innominate vein to the SVC
used. In normal individuals, there should be a minimal and right atrium
(less than 10 mm Hg) interarm systolic pressure • IN is less likely affected by extrinsic compression from
gradient during a routine examination. A consistent other structures in neck
difference in pressure between the arms greater • Veins in the left side of the neck reach the heart by crossing
than 10 mm Hg is suggestive of (and greater than the mediastinum, where they may be compressed by the
20 mm Hg is diagnostic of) subclavian or axillary normal aorta; causing the left jugular venous pressure
arterial stenosis, which may be observed in individuals to appear elevated even when the CVP and right atrial
at risk for atherosclerosis (Fig. 2B.25). pressures are normal.
 7

Ankle-brachia! Index Brachial difference

.-- --- --- -- --- 125 : 120
Traditional . Higher ankle pressure BO: Higher brachia! pressure-·
method • Higher brachia! pressure Lower brachia! pressure

Alternative . Lower ankle pressure

method • Higher brachia! pressure

Traditional:
ABI 125
I
130 = 1.04I
BD: 125- 120 =[§)

Alternative:
ABI 125
I I
110 = 0.88
DP
130 -~'- -'

PT
110
Fig. 2B.25: Calculating ankle brachia I index.

Why internal jugular vein preferred over. e~!~r • The patient's neck shou ld be slightly turne d towar
nal jugular_vein
for JVP assessment?
Internal jugular
• ' ~·)· ..- ......•
, . : '_57~·ft::i;1fj,<'.' ~)/:- !' • ,
External jugular
•\. 1

•
left side.
Shining a light tangentially across the neck may
help y
l
ds tll

Straight communication
with right atrium
Not in straight communication
with right atrium •
see the waveform.
Observe for puls ation betw een two head s
of sternc
I
Less valves More valves cleidomastoid.
Less influenced by fascia! • Trace the pulsation and locate the uppe r level
More kinked by fascia I planes .
planes • Take two scales. Place one scale at the uppe r
level oftli
Less affected by sympathetic More affected by symp JVP, parallel to the ground.
athetic \
system system • Now place the seco nd scale at the level of
the sterm
Vasoconstriction secondary to
angle, perpendicular to the first scale.
hypotension (in CCF) can make EJV • Measure the vertical heig ht on the seco nd scale
.
small and barely visible • Express as_ _ _cm of wate r above sternal
angle. Ad
5 cm to this value to dete rmin e the right atria
Differences between carotid and JVP l pressure.
• Conversion: 1.36 cm of H 0 or bloo d= 1 mm
Carotid pulse Jugular venous pulse 2 Hg
• The normal NP is less than 4 cm above the stern
Better felt Better seen al angle
or is just visible above the clavicle in 45° posit
Cannot be obliterated ion.
Can be obliterated (by pressure • Normal CVP is <7 mm of Hg or 9 cm H 0.
at root of neck) 2
One positive wave Two positive and two negative

Medially_ sefill
waves
Laterally seen
jU
Seen in Lo~~rpar:t Seen in upper part
Definite upper level absent .__ _ _ _ lnnominate
Definite upper level present
Expansile impulse (outward) Retractile impulse (inward). . - - - - - - - - - - - Superior
Descents >obvious than crests vena cava
Does not change with position Changes with positi
on
Does not change with Changes with respiration
respiration
Does not change with Changes with abdominal
abdominal compression compression Right
ventricle
Steps ofExamination ofJVP (Figs. 28.27 and
28.28)
• Patie nt com forta bly lying in semi recli ned posi
tion (45°
position). Fig. 28.26: Anatomy of the right UV.