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Slide1
Cardiopulmonary History and Exam
Wendy Blount, DVM
Slide2Housekeeping
Dylan
is our “concierge”Let her know if you need another note pad
Or anything else!Course materials are also downloadable at
http://wendyblount.com
Direct link:
http://
wendyblount.com/cardiology.php
Click on Presentation Notes
Slide3Dylan is our “concierge”
Let her know if you need another note pad
Or anything else!
Course materials are also downloadable at
http://wendyblount.com
Direct link:
http://wendyblount.com/cardiology.php
Click on Presentation Notes
Housekeeping
Slide4Housekeeping
Click on this presentation at the top
Slide5Click on this presentation at the top
Housekeeping
Slide6Seminar Packet:
Flash DriveAgenda
Evaluation
CE Certificatepen and notepad
List of AbbreviationsHank and Eli Fund, Dark Horse Lodge info
Cardiology Form, GlobalFAST® Forms & Handouts
Instructions for screen sharing
Info on hands-on ultrasound training
Housekeeping
Slide7F
lash Drive:
All PowerPoints with embedded videos
.pdfs of PowerPoints – 1 and 6 slides per page
Forms – in clinic and lab submission
Scientific articles
Diagnostic and treatment aid handouts
Agenda, abbreviations, instructions for following along
Hank and Eli Fund, Dark Horse Lodge info
Housekeeping
Slide8We will take a 5 minute break each hour and a
half, but take your own breaks as you wish
PLEASE PARTICIPATE!!!
But take private conversations outside or, in the classroom or store
Get
your CE certificate signed at the end of each day
If you leave early, the time will be added to the form
Pretty Please fill out the Course Evaluation form
Leave with DylanHousekeeping
Slide9Smoking outside the entrance, in the designated area
Restrooms through the door at the back of the room, and to the left of the classroom
Lunch will be served there There is no cell service in the building – enable WiFi Calling
WiFi: MeadowRidge Password: safety01
Our Host
Slide10IR (non-contact) temperature at morning sign in
Anyone with a fever will not be admitted
Tables & chairs disinfected with Rescue dailyRescue wipes and spray at the sanitation table
Treat it like a surgery tableUse hand sanitizer each time you access the table
Masks are encouraged but not requiredIf you come within 6 feet of another person, please wear your mask – especially during breaks, meals and the dry lab, and especially for people >65yrs
Social Distancing
Slide11Those who are
already significantly exposed to each other prior to the seminar may
share a tableNo more than 2 people at a table
The seat you have chosen is yours for the weekend Place
OCCUPIED table marker in your packet on your table, so others know it is reserved for you.
Wear the
HIGH RISK nametag
in your packet if you wish
Hand sanitizer at your table – use it oftenWash your hands as often as is possibleNo touching anyone else’s table or chair or ANYTHING YOU CAN AVOID TOUCHING!Social Distancing
Slide12When lining up for food or dry lab, please stay 6 feet behind the next person
MASKS ARE REQUIRED FOR THE DRY LABFood will be served to you, and single use condiments are available on request
Sanitize hands before (and after if you can)touching any doorknobs or other shared items
Touching the sign-in table – Dylan will sign you in and I will sign you out
Touching anything but your stuff on your table
Social Distancing
Slide13Screen at the front of the roomFlash Drive
.pdfs of PowerPoints - 1 & 6 slides/page.pptx of PowerPointsFiled in section folders
Website – updated PowerPointshttp://wendyblount.com/cardiogy.php
Screen Sharing: www.startmeeting.com
Click on the “join” button at the top rightFollowing Along
Slide14Following Along
Screen at the front of the room
Flash Drive
.pdfs of PowerPoints - 1 & 6 slides/page
.pptx of PowerPoints
Filed in section folders
Website – updated PowerPoints
http://wendyblount.com/cardiogy.php
Screen Sharing: www.startmeeting.comClick on the “join” button at the top right
Slide15Screen at the front of the room
Flash Drive
.pdfs of PowerPoints - 1 & 6 slides/page
.pptx of PowerPoints
Filed in section folders
Website – updated PowerPoints
http://wendyblount.com/cardiogy.php
Screen Sharing: www.startmeeting.comClick on the “join” button at the top right
Following Along
Slide16Screen at the front of the room
Flash Drive
.pdfs of PowerPoints - 1 & 6 slides/page
.pptx of PowerPoints
Filed in section folders
Website – updated PowerPoints
http://wendyblount.com/cardiogy.php
Screen Sharing: www.startmeeting.comClick on the “join” button at the top right
Following Along
Slide17Screen at the front of the roomFlash Drive
.pdfs of PowerPoints - 1 & 6 slides/page.pptx of PowerPointsFiled in section folders & PowerPoint folder
Website – updated PowerPointshttp://wendyblount.com/neurology.php
Screen Sharing: www.startmeeting.comClick on the “join” button at the top right
Following Along
Slide18As referral medicine becomes more advanced, it by default becomes more expensive
There is a growing gap between general practice and specialty practices
These seminars intend to fill that gapEverything we talk about this weekend can be done in a rural mixed animal practice with no emergency clinic or specialists within a few hours
DISCLAIMER – I AM NOT A SPECIALIST
Practical VetMed Philosophy
Slide19Our Goal for the
Weekend:Review
common things in detailCover
uncommon things in less detailRecognize
them and refer to the proceedings
Increase
level of care at your
clinic
And/or be better referring vetsBuild relationships with your colleaguesTexasVets list – Rosemary Lindsey, moderator
rosemarylindsey@sbcglobal.net
Practical VetMed Philosophy
Slide20Hank & Eli’s
Fund is
a
source of financial support
for active
duty service
men and women,
retired veterans’ service animals, and retired military animals
with veterinary medical
bills
There is a one page flyer
in your packet
Letter from Colton’s mother
on flash drive
Donation box on Dylan’s desk
give online
:
http://www.hankandeli.com
Mail donations to address on flyer
Free PowerPoint Templates
Hank & Eli’s Fund – Dark Horse Lodge
$3302
so far…
Slide21Free PowerPoint Templates
Hank & Eli’s
Fund
Slide22Free PowerPoint Templates
Hank & Eli’s
Fund
Southside Animal Hospital
6940 S Padre Island Dr
Corpus Christi TX 78412
(361) 993-7388
mmooremailforme@yahoo.com
If you want a collection box for your clinic,
contact Dr. Mike Moore
Slide23Slide24Signalment
Age
Congenital disease young
Myxomatous Valvular Diseaseold
ExceptionsCavalier King Charles Spaniels
mild PDA, PS, SAS
Reverse PDA
HCM in purebred cats
Slide25Signalment
Breed
Boston TerrierCavalierCocker Spaniel
Boxer Doberman
English BulldogGolden Retriever
HBT,
ColTr
C
VDDCM, PS, PDA, 3rdAVHBT, PS, SAS
DCM, Boxer CM, ASD
DCM (Arrhythmia?)
SAS, PS, CVDSAS
Slide26Signalment
Breed
Great DaneGSDIrish Setter
Irish WolfhoundKeeshondLabrador
Maine CoonNewfoundland
DCM, CVD
PRAA, SAS, PDA
PRAA
DCMToF (define), MVDTVD
HCMDCM, SAS
Slide27Signalment
Breed
Persian/HimalayanPointerPoodle
St BernardSamoyedSchnauzer
Springer SpanielYorkie
HCM
PRAA, SAS
CVD, PDA, CB
DCMASD, PSSSS, CVD, PS, CBVSD
CVD, CB, CT
Slide28History - Collapse
How can you tell the difference between seizure and syncope?
Urination/defecation/vocalization/
paddlingStiff/opisthotonus or flaccid
Narcolepsy, exercise induced collapseTwitching and muscle fasciculations
Cyanosis, pallor
Abnormal behavior before and after
Duration of stiffness/opisthotonus
Many times, you can’t (especially when short)
Slide29History - Collapse
What causes syncope?
BradyarrhythmiaPeriod of asystole
TachyarrhythmiaObstruction of blood flow to or from the heart
Inability to deliver oxygen to the brain, especially when there is increased demand
Decreased CO - Heart Failure**
Lung/airway disease
Anemia or other RBC/Hb problem
Slide30History - Collapse
What causes syncope?
Bradyarrhythmia3rd
degree heart block (define)
Sick sinus syndrome
(define)
Period of asystole
Sick sinus syndrome (SSS)Vagal surge (examples)Abdominal dz & retchingIntubation (brachycephalic)
Slide31History - Collapse
What causes syncope?
Tachyarrhythmia burst
Vtach (define, causes)B
oxer C
ardio
M
yopathy
Myocarditis (Chagas, Parvovirus)Myocardial hypoxiaAbdominal pathology (spleen)Supraventricular tachycardia (SVT) (define)Re-entry pathway (define)
Atrial fibrillation (Afib)SSS
Slide32History - Collapse
What causes syncope?
Obstruction of a great vessel or heart chamberThrombus (clot or HWDz)
NeoplasiaExtramural mass
Increased oxygen demand can not be met due to severe cardiovascular or pulmonary disease
AKA Exercise intolerance
Slide33History - 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, acting like something caught in the throat
Coughing up blood tinged fluidCough when drinking water, on tracheal palpation, or exercise induced cough
Presence of a murmur
(big dog, little dog, cat)
Many times, you can’t without PE/diagnostics
Slide34History - Cough
Cough on tracheal palpation
Any dog or cat will cough a few times on vigorous tracheal palpationProlonged coughing after tracheal palpation often indicates pathology (cardio or resp?)
equally likely with airway disease and cardiovascular disease
Slide35History - Cough
Dogs vs Cats
Coughing cats
much more likely to have respiratory disease than heart failureCats with heart failure more often present with acute and severe dyspnea, with no cough
Some cat owners can find it difficult to distinguish vomiting, gagging and coughingCoughing dogs can have either or both
Slide36Exam – Stethoscopes
Ear pieces fit snugly in the ears
Angle fits your ear canalsPoor fit, and you’ll miss low intensity murmurs
Tubing longer than 18 inches will dampen sounds
Electronic stethoscopes (microphone based)Difficult to distinguish heart from lung sounds
Difficult to distinguish patient from background noise
Meditron
sensor based scope
eliminates problemsConnect to computer & record for PCG consult
Slide37Exam – Stethoscopes
Pediatric stethoscope (
infant & pediatric sizes
)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
Slide38Exam – Stethoscopes
Cardiology Stethoscope - Diaphragm
Filters out low frequency sounds to hear high frequency sounds better
Press firmly against the chest
BellFor low frequency sounds (S3 S4 in dogs)
Press gently against the chest
Slide39Auscultation
Minimizing patient noise
Panting, whining – close mouth, occlude nostrilsPurring ( audio
)Aversives – turn water on, show another animal
Gentle pressure on the larynxCotton ball with alcohol to the noseJiggle the doorknob
Sometimes sedation is needed (
chart
)
Acepromazine 0.0125-0.025 mg/lb, maximum 1 mg per dogButorphanol 0.1 mg/lb or buprenorphine 0.01-0.02 mg/kgIV the fastest and most profound (30-45 minutes)
Slide40Auscultation
Patient is standing in a quiet place
R Lateral recumbency and listen from bottom if muffledFirm pressure with the diaphragm to avoid hair noisesget comfortable ausculting heart and palpating pulses at the same time
Listen at least 5 min for cardiac patientsHeart - R and L apex, L bases
L armpit (30 sec+ each)
Lungs – RCr, RMid,
RDCd,
LCr, LMid, LDCd
(20 sec+ each)
Slide41Auscultation
Is the murmur hemodynamically significant?
Prolonged and loud - yes
Pansystolic - yes
Diastolic - yes
Low intensity
- maybe
Early systolic
- maybeMusical – maybe not so muchLoudness is not necessarily correlated to presence of heart failure
Slide42Auscultation – Lung Sounds
Snaps crackles and wheezes
(cardio or resp?)More likely respiratory in dogs
(audio)
Not very sensitive for pulmonary edemaBeware similar hair rubbing noises
Pleural/pericardial Rubs
(
pleural rubs) (pericardial rubs)Dull/absent lung sounds (dog vs cat) (causes)Lung consolidationPneumothorax, pleural effusion (TFAST®
)Harsh lung sounds with no murmur in cat
think asthma or heartworm disease (
audio)
Slide43Auscultation - Heart Sounds
Normal Heart Sounds
Slide44Auscultation - Heart Sounds
Normal Heart Sounds
S1
AV Valves closeBeginning of systole/End of diastoleS2
Semilunar valves closebeginning of diastole/End of systole
Tachycardia – which is which?
S2 shorter and higher frequency
(
audio)Pulse is during systole
Slide45Auscultation - Heart Sounds
Variable intensity S1
Arrhythmia (variable FS)
Louder S1 (AV slamming)
Young, narrow chested dogs (Doberman
)
Increased sympathetic tone
Anemia
(decreased blood viscosity)FeverHypertensionAdvanced mitral valve disease
Slide46Auscultation - Heart Sounds
Quieter S1
(AV softly closing or muffled)Obesity, barrel chested dogs
Myocardial failure (decreased FS)
Pronounced 1st degree heart block
Hypervolemia
(IV fluids, hypernatremia, LHF)
Slide47Auscultation - Heart Sounds
Louder S2
(SL slamming)Hyperthyroidism
Fever, anemiaHeartworm DiseaseCor pulmonale
(define)Quieter S1-S2
(SL softly closing)
Myocardial failure (DCM, severe MR)
Obesity, barrel chested
Slide48Auscultation - Heart Sounds
Third Heart Sound (Gallop)
S3 (S1-S2-S3)
S4 (S4-S1-S2)Split S2Systolic Click
Summation Gallop (S4-S1-S2-S3)
Slide49Auscultation - Heart Sounds
Third Heart Sound
S3 – protodiastolic gallop (S1-S2-S3)
Rapid LV filling – early diastole (audio
)PMI R or L apex – low frequency (best heard with the bell)
At maximal mitral opening (E point on echo)
stiff LV or large diastolic volume
HCM, RCM, DCM, severe MR
Indicates myocardial failureUsually a bad mamma jamma
Slide50Auscultation - Heart Sounds
Third Heart Sound
S4 – presystolic gallop (S4-S1-S2)Atrial contraction -
Late diastole (audio)
PMI R or L apex, low frequency (bell)Stiff LV (HCM)
Increased afterload
3
rd
degree AV blockMyocardial failure (DCM, bad MR)Sometimes heard in normal cats & giant dogsnot necessarily a bad mamma jamma
Slide51Auscultation - Heart Sounds
Third Heart Sound
Split S2
PMI right heart base (left side)
AoV PV don’t close at same time (PV later)Reverse PDA
Pulmonary hypertension (HWDz, COPD)
Severe RBBB
relative PS of right to left shunts (ASD)
normal variation in large dogs (audio)
Slide52Auscultation - Heart Sounds
Third Heart Sound
Systolic Click
Very sharp, high frequency click of Mitral valve prolapse, in early MVD
Snapping of the chordae tendinae as they go taughtPMI left apex
Mid-Systolic (
audio
)
May be accompanied by a systolic murmurEarly, late, or holosystolic (audio)Often years until CHF develops, if at all
Slide533 Heart Sounds
How Can you tell the difference?
Does it Matter?Systolic less likely pathogenic (
S1-S2-S3)Systolic Click sounds sharper
Diastolic more likely pathogenic (
PMI L base)
(
S4-S3-S1
)How Can you tell if S3 or S4?Can’t tell if heart rate is > 160-180 (summation)just do a cardio work-up
Slide541 – left apex (MV)2 – left base (AoV)
3 – right base (PV) – ausculted on the left
4 – right apex (TV)
5 – left armpit (PDA)
5
Auscultation –
Heart Sounds
PMI
leftright
Slide55Auscultation – Heart Sounds
PMI (Point of Maximal Intensity)
Left Apex – at palpable apical bea
t S1 - MR (
mild MR) (
severe MR
)
Left Base –
slide cranially & a little dorsallyS2 - SAS (audio)S1, S2 - Ao endocarditis (audio
)Right Base (left side)
S2 - PS (
mild PS) (severe PS
)
Left Axilla
continuous - PDA (
PDA
) (
severe PDA
)
Right Apex
S1 – TR – like MR but often quieter (
audio
)
Slide56Auscultation – Heart Sounds
Muffled Heart Sounds
(causes)
Pleural, Pericardial effusion (*difference*)
Diaphragmatic hernia, thoracic massesObesity
What besides cardiac disease can cause a pathologic murmur?
Anemia
hypoproteinemia
Slide57Auscultation – Heart Sounds
Why do puppies have innocent murmurs?
Musical, grade 1-2, short
(audio
) (mild MR)
Larger SV relative to great vessel size
Lower PCV and plasma proteins
Artifact – high frequency breath sounds
They tend to be musical and relatively quiet
Slide58Auscultation – Heart Sounds
Why do cats have innocent murmurs?
Short systolic murmur at the sternum (
audio)
Not pansystolic and usually not holosystolicSympathetic tone
episodic hypertension, increased SV
Can come and go during a vet visit
Slide59Auscultation – Murmur Grade
Grade 1
Heard in a very quiet room, concentrating
Grade 2easily heard on the PMI - focal
Grade 3
Moderately loud
Grade 4
Very loud over much of the chest
Grade 5Heard with edge of stethoscope on chest, palpable thrillGrade 6Heard with stethoscope off chest, palpable thrill
Slide60Auscultation – Murmur Grade
High grade murmurs are more likely to be associated with severe disease
Severe disease can also be present with low grade murmur
Occasionally no auscultable murmur in the cat (dog?)DCM
ASDVSD
Reverse PDA (right to left shunting)
Dogs almost never have CHF without a murmur
Cats can have CHF without a murmur
Slide61Auscultation – Lung Sounds
6 points
3 Right, 3 Left – correspond to lung lobes
Slide62Auscultation – Murmurs
Holosystolic –
you can still make out S1 & S2
Starts at the end of audible S1Ends at the start of audible S2Murmur between the heart sounds
( VSD
)
Slide63Auscultation – Murmurs
P
ansystolicStarts before/at the beginning of S1
Ends at/after the end of S2Just hear the murmur with no distinct HS
( severe MR
)
(
severe SAS
)( severe PS )
Slide64Respiratory Sinus Arrhythmia
Heart rate increases during respiration
Due to increased vagal toneNormal variation in dogs (
not cats)No pulse deficits
If present, heart failure is not likelyIncreased sympathetic tone overrides
Pronounced in disease processes of increased vagal tone
Increased CSF pressure
Chronic respiratory disease
Thoracic or abdominal diseaseAfter sedation
Slide65Respiratory Sinus Arrhythmia
DDx
Afib with a normal ventricular rateFrequent APCs or VPCs (maybe pulse deficits)
Intermittent SSS
None of these vary consistently with the respiratory cycleRSA is regularly irregular
Others are usually irregularly irregular
(
RSA
) (PS with RSA)
Slide66Physical Exam – Ascites
most common cause of cardiogenic ascites in cats
TVD > VSD
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
or caval syndrome
Slide67Exam – Mucous Membranes
Cyanosis
> 4 g/dL of deoxygenated Hb in the blood
Severely anemic animals don’t turn blueEven with life threatening hypoxia
Differential cyanosis (define)
Front of body pink, back of body blue
Reverse PDA, FATE
(why rPDA)
Compare pulse oximetry or blood gases from front of body with rear of bodyWeak or no femoral pulses, pain, paresis with FATEUSE YOUR COLOR DOPPLER!!!
Slide68Exam – Pulses
Technique
Occlude the pulseThen slowly release pressure until maximum pulse is detected
Pulse Pressure = Systolic – Diastolic
Femoral pulse usually not palpable when MAP <50mmHgDorsal pedal pulse not palpable when SAP <80mmHg
Slide69Exam – Pulses
Bounding Pulses (water hammer)
Increased systolic pressure (increased SV) (causes)
Aortic regurgitationSevere bradycardia
Thyrotoxicosis (define EF, FS)
Fever
Anemia/hypoproteinemia
decreased diastolic pressure (diastolic runoff)
PDAAV fistulaAortic regurgitation (most common cause)Aortic endocarditis > SAS
Slide70Exam – Pulses
Weak Pulses
Severely decreased SV – severe forward LHF
Acutely decreased SV – hypovolemiaDecreased peripheral vascular resistance (shock)
Decreased arterial compliance (hypertension)
Pulse peaks slowly and late in systole (
feel the squirt
)
Pulsus parvus et tardus (cause)Severe SAS
Slide71Exam – 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
Slide72Exam – Pulses
Alternating Weak and Normal Pulses
Pulsus alternans
Severe myocardial failure (define MF vs CHF) (causes)DCM
RCM, UCM (define)
End stage valvular disease
Prolonged tachyarrhythmia or tachycardia
Slide73Exam – Pulses
Pulse Deficits (heart beat generates no pulse)
VPCs
Atrial fibrillation with VPCsTachyarrhythmia (inadequate filling)
Every other heart beat has a pulse deficitPulsus bigeminis
Caused by ventricular bigeminy
(define)
Totally chaotic heart sounds and pulses
(audio)Lots of multiform VPCs, Atrial fibrillationDelirium cordis –
like tennis shoes in a dryer
Slide74Exam – 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 H
2
0 in cats, 5-8 cm H
20 in dogsOr less often jugular or caval occlusionJugular Pulse (normal dogs cats)5-8cm dorsal to RA in dogs, 2-3 cm in cats (1/3 way up)
Too high indicates increased right heart pressure
If abnormalities above not noted, occlude at thoracic inlet, and releaseHepatojugular reflux
Slide75Exam – Jugular Veins
Jugular distension, high pulse, +HJR
(causes)Jugular/caval occlusion
Heartworm diseaseExternal mass (cyst, abscess, granuloma, neoplasia)
Thrombus (causes)
Decreased RV compliance
RV hypertrophy
PS, TOF, pulmonary hypertension
Restrictive CMRVOT obstructionHeartworm disease, neoplasia, thrombus
Slide76Exam – Jugular Veins
Jugular distension, high pulse, +HJR
RV volume overload
TR with RHFVSD
HWDzCompression on the RV, so it can’t fill
Pericardial effusion
constrictive pericarditis
Pericardial mass
Evaluation of CdVC, hepatic & splenic veins on US are more sensitive for increased RV pressure than jugular vein exam
Slide77Exam – Extremities
Peripheral edema
rareOften accompanied by diarrhea
Due to RHF, including end stage biventricular failure
Cold extremitiesDue to RHF and venous stasis
Or saddle thrombus
Acutely painful, followed by lack of pain
( Cardiovascular Exam form )
Slide78Summary
PowerPoints
- .pptx,
.pdfs – 1 or
6 slides per page
Form
– Cardiovascular Exam
.docx
, .pdfVet HandoutsSedation Doses and Echo Values by Weight
Fluid Analysis Diagnostic Chart
Audio Files
(29) – thoracic auscultation
Slide79Summary
Hidden Slides
List of common cardiovascular diseases by breed
More Details on gallop murmursQuiet heart sounds
Slide80Acknowledgements
Smith FWK, Keene BW, Tilley LP
Rapid Interpretation of Heart and Lung Sounds, 2nd ed, 2006
Kvart C & Haggstrom J
Cardiac Auscultation and Phonocardiography, Veterinary Information Network
Kittleson M
Small Animal cardiovascular
M
edicine, Veterinary Information Network. Chapter 3 – Signalment, History and Physical Examination