Cardiopulmonary History and Exam

1. Cardiopulmonary History and Exam Wendy Blount, DVM Nacogdoches TX

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

3. 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

4. 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

5. 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

6. 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)

7. 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)

8. 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)

9. 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

10. 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

11. 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

12. 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

13. 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

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

15. 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

16. 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)

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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