Cardiopulmonary History and Exam

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Cardiopulmonary History and Exam

• Wendy Blount, DVM
• Nacogdoches TX

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Signalment

• Age
• Congenital disease
• young
• Myxomatous valvular Disease
• old
• Exceptions
• Cavalier King Charles Spaniels (dz)
• PDA (why)
• Reverse PDA (define, why)

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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
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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
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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
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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 cant (especially when short)

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History - Collapse

• 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)

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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)

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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

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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 cant without PE/diagnostics

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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

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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

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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 (audio)
• Dull/absent lung sounds (dog vs cat) (causes)
• Lung consolidation
• Pneumothorax
• pleural effusion
• Harsh lung sounds with no murmur in cat
• think asthma

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Auscultation - Heart Sounds

• Normal Heart Sounds
• HS1
• AV Valves close
• Beginning of systole
• HS2
• Semilunar valves close
• end of diastole

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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

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Auscultation - Heart Sounds

• Third Heart Sound
• Split 2nd Heart Sound
• AoV PV dont 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)

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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?
• Cant tell if heart rate is gt 160-180
• Doesnt matter do a cardio work-up

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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

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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

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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

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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
  dont notice until huge
• If truly does develop over days, think
  pericardial tamponade

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Exam Mucous Membranes

• Cyanosis
• gt 4 g/dL of deoxygenated Hb in the blood
• Severely anemic animals dont 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

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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
  lt50mmHg
• Dorsal pedal pulse not palpable when SAP lt80mmHg

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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 gt SAS

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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

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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

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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

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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 (audio)
• Losts of multiform VPCs
• Atrial fibrillation

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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

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Exam Jugular Veins

• 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

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Exam Jugular Veins

• Jugular distension, high pulse, HJR
• RV volume overload
• TR with RHF
• VSD
• HWDz
• Compression on the RV, so it cant fill
• Pericardial effusion
• constrictive pericarditis
• Pericardial mass
• Evaluation of hepatic splenic veins on US are
  even more sensitive for increased RV pressure

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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

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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
• Wont localize murmurs properly in cats and small
  dogs

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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