cardiopulmonary history and exam wendy blount, dvm nacogdoches tx wendy blount, dvm nacogdoches tx

Cardiopulmonary History and ExamCardiopulmonary History and Exam

Wendy Blount, DVMNacogdoches TXWendy Blount, DVMNacogdoches TX

SignalmentSignalment

Age• Congenital disease

– young

• Myxomatous valvular Disease– old

• Exceptions– Cavalier King Charles Spaniels (dz)

– PDA (why)

– Reverse PDA (define, why)


Breed• Boston Terrier• Cavalier• Cocker Spaniel• Boxer

• Doberman• English Bulldog• Golden Retriever

HBT, CollapsingTrValvular DzDCM, PS, PDA, 3rdAVHBT, PS, SASDCM, Boxer CM, ASDDCM (Afib)

SAS, PS, MVDSAS


Breed• Great Dane• GSD• Irish Setter• Irish Wolfhound• Keeshond• Labrador• Maine Coon• Newfoundland

DCM, MVDPRAA, SAS, PDAPRAADCMTOF (define), MVDTVDHCMDCM, SAS


Breed• Persian/Himalayan• Pointer• Poodle• St Bernard• Samoyed• Schnauzer• Springer Spaniel• Yorkie

HCMPRAA, SASVDz, PDA, CBDCMASD, PSSSS, VDz, PS, CBVSDVDz, CB, CT

History - CollapseHistory - Collapse

How can you tell the difference between seizure and syncope? – Urination/defecation/vocalization/paddling– Stiff/opisthotonus or flaccid

• narcolepsy– Twitching and muscle fasciculations– Cyanosis, pallor – Abnormal behavior before and after– Duration of stiffness/opisthotonus

Many times, you can’t (especially when short)


What causes syncope?

– Bradyarrhythmia• 3rd degree heart block (define)• Sick sinus syndrome (define)

– Period of asystole• Sick sinus syndrome• Vagal surge (examples)

– Abdominal dz & retching– Intubation (brachycephalic)


What causes syncope? – Tachyarrhythmia burst

• Vtach (causes)

– BCM– Myocarditis– Myocardial hypoxia– Abdominal pathology (spleen)

• Supraventricular tachycardia (SVT) (define)

• Re-entry pathway (define)

• Atrial fibrillation (Afib)• SSS (3 ways)


What causes syncope?

– Obstruction of a great vessel or heart chamber•Thrombus•neoplasia

– Increased oxygen demand can not be met due to severe cardiovascular or pulmonary disease• AKA Exercise intolerance

History - CoughHistory - Cough

How can you tell the difference between cardiac and respiratory cough/dyspnea? – Honking cough– Soft moist cough– Dry hacking cough– Coughing/gagging up white foamy fluid– Coughing up blood tinged fluid– Cough when drinking water– Exercise induced cough– Presence of a murmur (big dog, little dog)

Many times, you can’t without PE/diagnostics


Cough on tracheal palpation

– Any dog or cat will cough a few times on vigorous tracheal palpation

– Prolonged coughing after tracheal palpation often indicates pathology (cardio or resp?)

– Prolonged coughing equally likely with airway disease and cardiovascular disease


Dogs vs Cats – Coughing cats

• much more likely to have respiratory disease than heart failure

• Cats with heart failure more often present with acute and severe dyspnea

• Some owners can find it difficult to distinguish vomiting from coughing

– Coughing dogs can have either or both

Auscultation – Lung SoundsAuscultation – Lung Sounds

• Snaps crackles and wheezes (cardio or resp?)

– More likely respiratory in dogs (audio)

– Not very sensitive for pulmonary edema

• Pleural/pericardial Rubs (audio)

• Dull/absent lung sounds (dog vs cat) (causes)

– Lung consolidation– Pneumothorax– pleural effusion

• Harsh lung sounds with no murmur in cat– think asthma

Auscultation - Heart Sounds


Normal Heart Sounds• HS1

– AV Valves close– Beginning of systole

• HS2– Semilunar valves close– end of diastole



Third Heart SoundHS3 – protodiastolic gallop

– Rapid LV filling - end of diastole– At maximar mitral opening (E point on echo)– stiff LV or large diastolic volume (audio)– HCM, RCM, DCM, severe MR

• HS4– Atrial contraction - Late diastole– Stiff LV or 3rd degree heart block (audio)– Sometimes heard in normal cats



Third Heart Sound• Split 2nd Heart Sound

– AoV PV don’t close at same time– Reverse PDA– Pulmonary hypertension– normal variation in large dogs– Systolic (audio)

Systolic Click– Very sharp click– Mitral valve prolapse– Systolic (audio)

Auscultation – 3 Heart Sounds

Auscultation – 3 Heart Sounds

How Can you tell the difference?Does in Matter?

– Systolic less likely pathogenic– Systolic Click sounds sharper– Diastolic more likely pathogenic

How Can you tell if systolic/diastolic?– Pulses happen during systole

How Can you tell if HS 3 or HS4?– Can’t tell if heart rate is > 160-180– Doesn’t matter – do a cardio work-up

Auscultation – Heart Sounds


PMI (Point of Maximal Intensity)Left Apex – at apical beat (S1 loudest)

– MR (audio)Left Base – cranial & dorsal (S2 loudest)

– PS (audio)– SAS (audio)– Aortic endocarditis (audio)

Left Axilla– PDA (audio)

Right Apex– TR

Right Base– TR, SAS



Muffled Heart Sounds (causes)

• Pericardial effusion• pleural effusion• obesityWhat besides cardiac disease can cause a

pathologic murmur?• Anemia• hypoproteinemiaWhy do puppies have innocent murmurs?• Musical• Larger SV relative to great vessel size

Auscultation – Murmur Grade

Auscultation – Murmur Grade

Grade 1• Heard in a very quiet room, concentratingGrade 2• Faint but easily heardGrade 3• Moderately loudGrade 4• Very loudGrade 5• Heard with edge of stethoscope on chest, palpable thrillGrade 6• Heard with stethoscope off chest, palpable thrill

Physical Exam – AscitesPhysical Exam – Ascites

• most common cause of cardiogenic ascites in cats (?)

– TVD• Tap and do fluid analysis to distinguish

between transudate, modified transudate and exudate (handout)

• Usually accumulates slowly, though owners often don’t notice until huge

• If truly does develop over days, think pericardial tamponade

Exam – Mucous MembranesExam – Mucous Membranes

Cyanosis• > 4 g/dL of deoxygenated Hb in the blood

– Severely anemic animals don’t turn blue– Even with life threatening hypoxia

• Differential cyanosis (define)– Front of body pink, back of body blue (examples)– Reverse PDA, FATE (why rPDA) (how to diagnose?)– Compare pulse oximetry or blood gases from front of body

with rear of body– Weak or no femoral pulses, pain, paresis with FATE

Exam – PulsesExam – Pulses

Technique• Occlude the pulse• Then slowly release pressure until maximum pulse

is detected

Pulse Pressure = Systolic – Diastolic• Femoral pulse usually not palpable when MAP

<50mmHg• Dorsal pedal pulse not palpable when SAP

<80mmHg


Bounding Pulses (water hammer)• Increased systolic pressure (increased SV) (causes)

– Aortic regurgitation– Severe bradycardia– Thyrotoxicosis (define EF, FS)– Fever– Anemia

• decreased diastolic pressure (diastolic runoff)– PDA– AV fistula– Aortic regurgitation (most common cause)

• Aortic endocarditis > SAS


Weak Pulses• Severely decreased SV – severe HF• Acutely decreased SV – hypovolemia• Decreased peripheral vascular resistance (shock)• Decreased arterial compliance (hypertension)

Pulse peaks slowly and late in systole• Pulsus parvus et tardus (cause)• Severe SAS


Short, Brisk Pulses (snappy)• Short, fast systole• Compensated MR (what happens to FS with MR)

Pulse weak or absent during inspiration• Pulsus paradoxus• Systolic pressure falls during inspiration• With pronounced respiratory sinus arrhythmia• Exaggerated by pericardial effusion


Alternating Weak and Normal Pulses• Pulsus alternans• Severe myocardial failure (define MF vs CHF)

(causes)

– DCM– RCM (define)

– End stage valvular disease– Prolonged tachyarrhythmia or tachycardia


Pulse Deficits (heart beat generates no pulse)• VPCs• Atrial fibrillation with VPCs• Tachyarrhythmia (inadequate filling)• Every other heart beat has a pulse deficit

– Pulsus bigeminis– Caused by ventricular bigeminy (define)

Totally chaotic heart sounds and pulses (audio)

• Losts of multiform VPCs• Atrial fibrillation

Exam – Jugular VeinsExam – Jugular Veins

• Clip or wet the fur over the jugular veins• Evaluate sitting or standing (not sternal)• Jugular Distension (causes)

– suggests increased RA pressure (normal dogs cats?)• 2-3 cm H20 in cats, 5-8 cm H20 in dogs

– Or less often jugular or caval occlusion• Jugular Pulse (normal dogs cats)

– 5-8cm dorsal to RA in dogs, 2-3 cm in cats– Too high indicates increased right heart pressure

• If abnormalities above not noted, occlude at thoracic inlet, and release

• Hepatojugular reflux


Jugular distension, high pulse, +HJR (causes)

• Jugular/caval occlusion– Heartworm disease– External mass (cyst, abscess, granuloma, neoplasia)– Thrombus (causes)

• Decreased RV compliance– RV hypertrophy

• PS, TOF, pulmonary hypertension– Restrictive CM– RVOT obstruction

• Heartworm disease, neoplasia, thrombus


Jugular distension, high pulse, +HJR• RV volume overload

– TR with RHF– VSD– HWDz

• Compression on the RV, so it can’t fill– Pericardial effusion– constrictive pericarditis– Pericardial mass

Evaluation of hepatic & splenic veins on US are even more sensitive for increased RV pressure

Exam – ExtremitiesExam – Extremities

Peripheral edema• rare• Often accompanied by diarrhea• Due to RHF

Cold extremities• Due to RHF and venous stasis• Or saddle thrombus

– Acutely painful, followed by lack of pain

Exam – StethoscopesExam – Stethoscopes

Pediatric stethoscope• For cats and small dogs• Will distort and decrease sound intensity if used on

a medium or large dog

Adult stethoscope• For medium to large dogs• Won’t localize murmurs properly in cats and small

dogs

Exam – StethoscopesExam – Stethoscopes

Diaphragm• Filters out low frequency sounds to hear high

frequency sounds better• Press firmly against the chest

Bell• For low frequency sounds (S3 S4 in dogs)• Press gently against the chest

cardiopulmonary history and exam wendy blount, dvm nacogdoches tx wendy blount, dvm nacogdoches tx

Documents

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mvd sas slide

ct slide

asthma slide

pediagnostics slide

short slide

cardiovascular disease

sas dcm