Transcript Name of presentation

Cardiopulmonary
History and Exam
Wendy Blount, DVM
Nacogdoches TX
Signalment
Age
• Congenital disease
– young
• Myxomatous valvular Disease
– old
• Exceptions
– Cavalier King Charles Spaniels
– PDA (why)
– Reverse PDA
(define, why)
(dz)
Signalment
Breed
• Boston Terrier
• Cavalier
• Cocker Spaniel
• Boxer
• Doberman
• English Bulldog
• Golden Retriever
HBT, CollapsingTr
Valvular Dz
DCM, PS, PDA, 3rdAV
HBT, PS, SAS
DCM, Boxer CM, ASD
DCM
(Afib)
SAS, PS, MVD
SAS
Signalment
Breed
• Great Dane
• GSD
• Irish Setter
• Irish Wolfhound
• Keeshond
• Labrador
• Maine Coon
• Newfoundland
DCM, MVD
PRAA, SAS, PDA
PRAA
DCM
TOF (define), MVD
TVD
HCM
DCM, SAS
Signalment
Breed
• Persian/Himalayan
• Pointer
• Poodle
• St Bernard
• Samoyed
• Schnauzer
• Springer Spaniel
• Yorkie
HCM
PRAA, SAS
VDz, PDA, CB
DCM
ASD, PS
SSS, VDz, PS, CB
VSD
VDz, CB, CT
History - 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)
History - Collapse
What causes syncope?
– Bradyarrhythmia
• 3rd degree heart block
• Sick sinus syndrome
(define)
(define)
– Period of asystole
• Sick sinus syndrome
• Vagal surge
(examples)
– Abdominal dz & retching
– Intubation (brachycephalic)
History - Collapse
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)
History - Collapse
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 - 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
History - Cough
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
History - Cough
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 Sounds
• Snaps crackles and wheezes
(cardio or resp?)
– More likely respiratory in dogs
(audio)
– Not very sensitive for pulmonary edema
• Pleural/pericardial Rubs
• Dull/absent lung sounds
(audio)
(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
Auscultation - Heart Sounds
Third Heart Sound
HS3 – 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
Auscultation - Heart Sounds
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
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
Auscultation – Heart Sounds
Muffled Heart Sounds (causes)
• Pericardial effusion
• pleural effusion
• obesity
What besides cardiac disease can cause
a pathologic murmur?
• Anemia
• hypoproteinemia
Why do puppies have innocent murmurs?
• Musical
• Larger SV relative to great vessel size
Auscultation – Murmur Grade
Grade 1
• Heard in a very quiet room, concentrating
Grade 2
• Faint but easily heard
Grade 3
• Moderately loud
Grade 4
• Very loud
Grade 5
• Heard with edge of stethoscope on chest, palpable thrill
Grade 6
• Heard with stethoscope off chest, palpable thrill
Physical 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 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 – 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
Exam – Pulses
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
Exam – Pulses
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
Exam – Pulses
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
Exam – Pulses
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
Exam – Pulses
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
• Losts of multiform VPCs
• Atrial fibrillation
(audio)
Exam – 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
Exam – Jugular Veins
Jugular distension, high pulse, +HJR
• Jugular/caval occlusion
(causes)
– 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
Exam – Jugular Veins
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 – 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 – 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 – 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