Accuracy of Physical Exam in Covid Era

Abstract

IntroductionPhysical examination remains central to the management of heart failure patients. The assessment of volume status guides medical management and estimation of prognosis. Jugular venous pressure (JVP) estimation is the most important and accurate part of the physical examination in heart failure patients to assess volume status. Telemedicine visits are now a common place across the nation due to the current pandemic. In this unique situation we conducted a study to assess the accuracy of JVP estimation during a telemedicine visit.MethodsThis is a retrospective observational study. All the patients who were seen via telemedicine visit in the advanced heart failure, LVAD and transplant clinics were considered. The patients who underwent a right heart catheterization (RHC) within two weeks of the telemedicine clinic visit were included in the study. JVP measured by physical examination was obtained from chart review. Invasive hemodynamic data was obtained from RHC. JVP assessment was done via tele assessment with the patient in sitting position. For the purpose of this study JVP on examination was estimated by the clinician as either a numerical number or by distance in relation to the clavicle and jaw. Majority of the patients were male (n = 10) and had a mean age of 57 years. Mean BMI of the patients was 30. Eight of the eleven were post heart transplant patients. Two patients had a left ventricular assist device (Heartmate II and HVAD devices) placed as Destination therapy.ResultsFrom April 1st 2020 to May 21st 2020 twenty patients were identified who underwent RHC two weeks after their telemedicine visit. Of these eleven patients had JVP documented at the time of telemedicine visit and were included in the study. Seven patients had JVD not detectable above the level of clavicle on examination. 85% (n = 6) of these patients had mean RA pressure less than 7 mm Hg on RHC. One patient had mean RA pressure 8 mm Hg. Two patients were documented to have a JVP of 10 cm H2O. Both these patients had JVP of 8 mm Hg on RHC. Two patients were documented to have JVP of more than 10 cm H20 and both these patients had mean RA pressure more than or equal to 12 mm Hg on RHC.90% (n = 10) of patients had accurate assessment of right-sided filling pressures by examination via tele visit.