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It usually occurs in dependent areas of the body, such levitra kaufen online as the ankles (pedal edema) for ambulatory patients or the sacral region for bedridden patients. Patients may complain of swelling of their feet and ankles, which can extend up to their calves or thighs. Abdominal congestion may cause a bloated feeling, abdominal pain, early satiety, nausea, anorexia, and constipation. Often patients may have difficulty fitting into their shoes or pants due to edema. Weight gain often precedes signs of overt peripheral edema. Therefore, it is crucial for patients to weigh themselves daily even in the absence of symptoms to assess fluid status. A clinically validated measure of venous congestion is assessment of the jugular venous pressure (jvp). This is performed by examining the right internal jugular vein for distention or elevation of the pulsation while reclining at a 45-degree angle. A jvp more than 4 cm above the sternal angle is indicative of elevated right atrial pressure. Jvp may be normal at rest, but if application of pressure to the abdomen can elicit a sustained elevation of jvp, this is defined as hepatojugular reflux (hjr).