Approach to diagnosis, PE

Question 1

Heart disease/Heart failure - define

Answer 1

Any animal with a detectable abnormality of the heart - heart disease
animals demonstrating clinical signs of forward or backward failure - heart failure e.g. dyspnoea, exercise intolerance, collapse

Question 2

Physical exam - steps

Answer 2

Observation
Palpation
Percussion
Auscultation

Question 3

observation

Answer 3

Demeanour
Respiratory effort and rate
Mucous membranes
Body condition
Venous congestion
Ascites

Question 4

mucous membranes - pallor

Answer 4

pale colour of skin
implies poor peripheral circulation with vasoconstriction or decr haemoglobin in circulating blood
differentiate on basis of PCV + arterial pulse quality

Question 5

mucous membranes - cyanosis

Answer 5

blue/purple discolouration
adequate haemoglobin but inadequate O2
problem with O2 - pleural effusion, pulmonary oedema
right to left shunt of blood in circulation so deoxygenated blood mixes with oxygenated blood then ejected into circulation

Question 6

venous congestion - observations

Answer 6

evidence of high venous pressure can be seen with jugular pulses or jugular venous distention
veins on ventral abdomen can be obvious

Question 7

palpation - precordium

Answer 7

Apex beat
Location
Intensity
Rate and Rhythm
Presence of thrill

Question 8

palpation - abdomen

Answer 8

Ascites
Concurrent disease
fluid thrill
hepatomegaly
splenomegaly

Question 9

palpation - pulse

Answer 9

Feel pulse at same time as ausculting heart
pulse rate = heart rate? - Pulse deficit when an audible contraction is not associated with a palpable pulse
Is pulse regular? - If it is irregular is it regularly irregular or irregularly irregular?
Describe the quality of the pulse -Inevitably subjective, strong, weak, thready, bounding
etc - can be BCS dependent

Question 10

Percussion - Precordium

Answer 10

Fluid lines

Areas of dullness

Question 11

percussion - thorax

Answer 11

may detect lack of resonance is consolidation of underlying lung
may detect fluid line

Question 12

percussion - abdomen

Answer 12

Detection of fluid thrill

Question 13

auscultation - left side

Answer 13

apex - caudal, mitral valve more audible S1 loudest

base - cranial, pulmonic and aortic valve more audible S2 loudest

Question 14

ausculation - right side

Answer 14

Tricuspid valve
Possibly aortic valve
Ventricular septal defects

Question 15

S1 sound

Answer 15

closure of atrioventricular valves in systole
usually loudest heart sound
heard best over left apex

Question 16

S2 sound

Answer 16

closure of pulmonic + aortic valves
represents end of systole
loudest at left heart base

Question 17

S3 sound

Answer 17

passive ventricular filling

ventricle relaxes + blood passively flows into the atria to the ventricle

Question 18

S4 sound

Answer 18

active ventricular filling as atria contract

blood forced into the ventricles

Question 19

S3 + S4

Answer 19

may be audible in normal large animals but not in small
audible diastolic sound implies ventricle is not filling properly i.e. poor relaxation
gallop rhythm

Question 20

splitting of S1 +/or S2

Answer 20

asynchronous closure of AV or outflow valve
split S2 can occur in pulmonary hypertension
pulmonic valve closes after aortic valve - 2 audible sounds rather than one

Question 21

murmur - define

Answer 21

prescence of turbulent flow in the heart due to disturbance to normal laminar flow of blood within the heart + surrounding vessels

Question 22

murmur - contributing factors

Answer 22

age
increased velocity of blood flow
inc volume of blood flow
decr blood viscosity
regurgitation of blood across insufficient valve
majority of small animal murmurs in systole

Question 23

Location of murmur - Left heart base

Answer 23

Typically hear pulmonic and aortic valve

Ribspaces 3/4 on left

Question 24

Location of murmur - Left heart apex

Answer 24

Typically hear mitral valve

Question 25

Location of murmur - right side

Answer 25

Typically hear tricuspid

VSD loudest on right

Question 26

descriptions of murmurs

Answer 26

Timing/Duration
Location
Intensity/Audibility
Radiation
Pitch
Shape

Question 27

murmur timings - systole

Answer 27

AV valves closed = M + T insufficiency
Outflow valves open = A + P stenosis
Aortic pressure > PA pressure = flow through P.D.A
LV pressure > RV pressure = flow through V.S.D

Question 28

murmur timings - diastole

Answer 28

AV valves open = M + T stenosis (low pressure)
Outflow valves closed = A + P insufficiency
Aortic pressure > PA pressure = flow through P.D.A.
LV pressure = RV pressure = No flow through V.S.D

Question 29

systole murmur locations

Answer 29

mitral insufficiency - left apex
aortic + pulmonic insufficiency - left base
ventricular septal defect - right sternal border
tricuspid insufficiency + aortic stenosis - right cranial

Question 30

diastole murmur locations

Answer 30

mitral stenosis - left apex
aortic/pulmonary insufficiency - left base
Aortic insufficiency +Tricuspid stenosis - right cranial

Question 31

grade of murmur

Answer 31

Grade I - barely audible, ideal conditions
Grade II - Clearly audible at PMI, does not radiate
Grade III - Clearly audible, as loud as S1 and S2, may radiate
Grade IV - Louder than S1 and S2
Grade V - Precordial thrill palpable
Grade VI - Audible with stethoscope off thorax

Question 32

radiation of murmur

Answer 32

Murmurs may radiate in a particular direction
Radiation means that a murmur is still audible in a particular direction as you go away from the point of maximal intensity
Aortic murmurs may radiate up the carotid arteries
Mitral murmurs may radiate dorsally

Question 33

pitch

Answer 33

Subjective description of the frequency of the audible sound associated with a murmur
high pitch - more likely ejection murmur
low murmur - regurgitant flow

Question 34

shape

Answer 34

Shape - Description of appearance on phonocardiogram
Crescendo decrescendo “diamond shaped”
Pansystolic “plateau”

Question 35

intensity of heart sound

Answer 35

may be muffled with pleural/pericardial fluid

marked if gross cardiomegaly