Approach to diagnosis, PE Flashcards
Heart disease/Heart failure - define
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
Physical exam - steps
Observation
Palpation
Percussion
Auscultation
observation
Demeanour Respiratory effort and rate Mucous membranes Body condition Venous congestion Ascites
mucous membranes - pallor
pale colour of skin
implies poor peripheral circulation with vasoconstriction or decr haemoglobin in circulating blood
differentiate on basis of PCV + arterial pulse quality
mucous membranes - cyanosis
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
venous congestion - observations
evidence of high venous pressure can be seen with jugular pulses or jugular venous distention
veins on ventral abdomen can be obvious
palpation - precordium
Apex beat Location Intensity Rate and Rhythm Presence of thrill
palpation - abdomen
Ascites Concurrent disease fluid thrill hepatomegaly splenomegaly
palpation - pulse
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
Percussion - Precordium
Fluid lines
Areas of dullness
percussion - thorax
may detect lack of resonance is consolidation of underlying lung
may detect fluid line
percussion - abdomen
Detection of fluid thrill
auscultation - left side
apex - caudal, mitral valve more audible S1 loudest
base - cranial, pulmonic and aortic valve more audible S2 loudest
ausculation - right side
Tricuspid valve
Possibly aortic valve
Ventricular septal defects
S1 sound
closure of atrioventricular valves in systole
usually loudest heart sound
heard best over left apex
S2 sound
closure of pulmonic + aortic valves
represents end of systole
loudest at left heart base
S3 sound
passive ventricular filling
ventricle relaxes + blood passively flows into the atria to the ventricle
S4 sound
active ventricular filling as atria contract
blood forced into the ventricles
S3 + S4
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
splitting of S1 +/or S2
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
murmur - define
prescence of turbulent flow in the heart due to disturbance to normal laminar flow of blood within the heart + surrounding vessels
murmur - contributing factors
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
Location of murmur - Left heart base
Typically hear pulmonic and aortic valve
Ribspaces 3/4 on left
Location of murmur - Left heart apex
Typically hear mitral valve
Location of murmur - right side
Typically hear tricuspid
VSD loudest on right
descriptions of murmurs
Timing/Duration Location Intensity/Audibility Radiation Pitch Shape
murmur timings - systole
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
murmur timings - diastole
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
systole murmur locations
mitral insufficiency - left apex
aortic + pulmonic insufficiency - left base
ventricular septal defect - right sternal border
tricuspid insufficiency + aortic stenosis - right cranial
diastole murmur locations
mitral stenosis - left apex
aortic/pulmonary insufficiency - left base
Aortic insufficiency +Tricuspid stenosis - right cranial
grade of murmur
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
radiation of murmur
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
pitch
Subjective description of the frequency of the audible sound associated with a murmur
high pitch - more likely ejection murmur
low murmur - regurgitant flow
shape
Shape - Description of appearance on phonocardiogram
Crescendo decrescendo “diamond shaped”
Pansystolic “plateau”
intensity of heart sound
may be muffled with pleural/pericardial fluid
marked if gross cardiomegaly
