Cardiovascular Examination Flashcards
1
Q
components of the cardiovascular exam
A
- Species
- Signalment
- Chief complaint
- History
- Examination of the peripheral arterial pulse
- Examination of the jugular veins
- Examination of the precordium
- Auscultation of the heart and lungs
- Additional diagnostic testing
2
Q
purpose of CV exam
A
- Determine the presence/absence of CV disease
- Help localize the anatomic site of CV disease
- Aid determination of the CV diagnosis
- Assess the severity (stage) of CV disease
- Inform the prognosis
- Dictate urgent therapy, if required
3
Q
neonates and pediatric animals have what type of CD
A
congenital heart dsiease
4
Q
old dogs have what type of CD
A
mitral valve degeneration
5
Q
middle aged cats often have what type of CD
A
hypertrophic cardiomyopathy
6
Q
old cats often have what type of CD
A
systemic disease and secondary CV effects (hyperthyroid)
7
Q
young horses often have what type of CD
A
heart rhythm disturbances (atrial fibrillation)
8
Q
old horses often have what type of CD
A
aortic valve degeneration
9
Q
cattle often have what type of CD
A
right atrial lymphoma, endocarditis, pericardial disease, high altitude
10
Q
PDA is more common in what sex of dogs?
A
female dogs
11
Q
HCM is more common in what sex of cats?
A
male cats
12
Q
T/F: animals with CV disease often have no notable signs
A
true
13
Q
why is client history super important with cardiac patients?
A
need to make sure there is no:
– Lethargy, exercise intolerance, reduced activity
– Separation, hiding behavior
– Syncope or exertional weakness
– Respiratory signs (cough, rapid breathing)
– Abdominal distension or subcutaneous edema
– Muscle/weight loss with chronic cardiac disease
– Acute paresis (limb lameness)
– Regurgitation
14
Q
exercise intolerance
A
may be a sign of several body systems
- musculoskeletal
- neuro
- metabolic
- CV
- nutritional
need thorough PE!!
15
Q
syncope
A
brief loss of consciousness and postural tone “fainting”
- primarily related to reduced cerebral blood flow
- may be caused by abnormal heart rhythms, excessive vasodilation; plasma volume contraction
16
Q
in horses, a sudden drop in performance may be the first sign of underlying
A
CV disease
17
Q
what other signs can occur with syncope?
A
paddling and loss of bowel/urination
seizure
these signs are not discriminatory! often looks like other things
hallmark is rapid return to normal
18
Q
twitching with syncope is normal in what species?
A
cats and horses
due to decreased cerebral perfusion
19
Q
respiratory signs pathogenesis with CV disease
A
- backup of blood behind a failing heart may cause fluid accumulation in the lungs or pleural space around the lungs
- dogs with heart disease often cough
- cats with seldom disease seldom cough; resp signs are more often related to tachypea or dyspnea
20
Q
T/F: dogs with heart disease rarely cough unless they are older
A
false- dogs with heart dz often cough
21
Q
T/F: cats with heart disease seldom cough
A
true- respiratory signs usually related to tachypena/dyspnea
22
Q
hyperpnea
A
deep breathing
23
Q
abnormalities in respiratory signs with CV disease
A
tachypena: fast
hyperpnea: deep
dyspnea: distress (sensation of struggling to breathe)
24
Q
exertional respiratory distress is seen in animals with what?
A
limited cardiopulmonary capacity:
– Pulmonary hypertension
– Cyanotic heart disease
– Severe systolic dysfunction
– Congestive heart failure
25
why is it important to teach an owner to count respiratory rate?
can detect early changes in lung water and potentially avoid emergent crises
take rate when animal is asleep: not panting/excited etc
usually see that days before overt clinical signs, the sleeping respiratory rate is increased
26
cough vs reverse sneeze
cough: forced exhalation
reversed sneeze: forced inhalation- sign of pharyngeal disease: something stuck in back of oropharynx
27
reverse sneeze is a sign of disease in what part of airway?
pharyngeal disease
28
abdominal distension
- cavitary effusion: common with R sided CHF in dogs
- subcutaneous edema common in large animals with CHF: whether L or R sided
29
cavitary effusion is often seen in dogs with what sided CHF?
right sided
30
swelling of extremities with CV disease?
high filling pressure, vascular obstruction, or vascular communication (AV shunt)
31
claudication
limb paresis
potential sign of arterial obstruction: rule out musculoskeletal and neurologic causes
32
cardiac cachexia
chronic heart failure results in a catabolic state
- protein loss in cavitary effusions
- edematous GI tract w poor absorption
- impaired perfusion of vital orgons
end result: severe muscle and condition loss
33
persistent R aortic arch can be seen with what clinical sign?
regurgitation
usually esophageal dysfunction
34
physical exam for CV system should focus on
– Evaluation of overall health – BCS, MCS, gait
– Attitude, posture, ease of breathing
– Mucous membrane color, refill time
– Arterial pulse quality (femoral, facial)
– Apical impulse / thoracic wall
– Jugular veins – distension, pulsation, hepatojugular reflux
– Careful auscultation over all cardiac valves and lung fields
The Cardiovascular Exam
35
evaluation of mucus membranes in cardiac exam
* Pale/white: Anemia; poor cardiac output, severe vasoconstriction
* Pink: Normal
* Red: Vasodilation, erythrocytosis
* Blue/Purple: Cyanosis (hypoxemia)
36
what limb abnormality can you see in cats with heart disease?
hind limb paw pads: can see difference in color (pink to cyanotic)
can be seen in ex of unilateral arterial occlusion (thromboembolism to femoral artery from severe heart dz)
37
pulse quality is affected by
1. difference between systolic and diastolic pressure
2. elasticity of artery
3. rate of rise of pressure
4. peak pressure in the veessel
38
normal arterial pulse
palpable with light touch
39
weak arterial pulse
hard to feel; occluded with light pressure
40
strong arterial pulse
easily palpable; hard to occlude with firm pressure; felt in small peripheral arteries
happens because of greater distance between diastolic/systolic pressure
41
causes of weak pulse
hypovolemia
poor cardiac output
LV outflow obstruction (SAS)
42
causes of strong/bounding pulse
– Abnormal diastolic runoff of blood (AV shunt, PDA, aortic regurgitation)
– Bradycardia causing longer diastole (wide pulse pressure)
– Vasodilation, reduced vascular resistance (fever, anemia, exercise, thyroid, drugs)
– High sympathetic tone
– Age and stiffening of the arteries
43
when do pulse deficits occur?
- abnormal heart rhythm causing heart to contract prematurely and close the AV valves (causing heart sound)
- but: stroke volume of the early heart beat may be inadequate to open the aoritc valve or lead to a palpable pulse in peripheral artery
44
hat are pulse deficits?
difference in what we hear/auscult in the heart compared to what is felt on the pulse
usually happens because of premature/abnormal beats
45
apical impulse + thoracic palpation
- palpation of thoracic wall over the heart
- heart enlargement can lead to caudal displacement
- vibration or "thrill" with abnormal flow (ex buzzing bees in hands)
46
distension of jugular veins tells you that what is going on?
- increased plasma volume
- possible tumor?
- impaired venous return from high pressure
difference between distension (increased filling pressure) and venous pulsation (reflected waves) = either stiff R ventricle with high atrial pressure goes back up, or a sign of tricuspid regurgitation as wave goes back up
47
what is the difference between jugular distension vs pulsation
pulsation: reflected waves
distension: increased plasma volume; impaired venous return
48
how can an ophtho exam help you determine CV dz?
fundic exam: retinal vessels, hemorrhage
can suggest high blood pressure, hyperviscosity
49
where are the valves on the left side of the patient
PAM on the left (cranial to caudal)
50
where are the valves on the right side of the patient
TV and ascending aorta
51
auscultation in cat
- locating valves challenging
- parasternal: left, right and cranial/caudal
- not necessarily discrete valve locations
- purring!!! use gentle pressure on larynx to limit purring
52
artifacts that obscure auscultation
* Respiration & Panting: May be louder than heart; can sound like a
murmur
* Purring: Obscures normal auscultation
* Excessive pressure: Compliant thorax (kitten, puppy, chinchilla) your
stethoscope pressure may compress vessels and cause a murmur
* Moving the chest piece over the fur
* Muscle twitches
53
what are we listening for when auscultating?
– Intensity (loud, soft, variable)
– Rate (fast, slow)
– Rhythm (regular, irregular)
– Pauses
– Extra sounds (premature beats, clicks, gallop, split)
– Murmurs
– Friction rubs
54
genesis of heart sounds
- transient sounds: abrupt changes in pressure and flow; short duration
- 1st heart sound: closure of mitral and tricuspid valve (AV) , then relaxes and aortic and pulmonary valves close (Semilunar) and that is the 2nd heart sound = lub dub
- large animals: can hear 3rd and 4th heart sounds: these are vibration associated with filling of the chambers = occur in diastolew
55
when do 3rd and 4th heart sounds occur?
during diastole (filling)
4th precedes the next heart beat
hear them in LARGE animals
56
how can heart sounds be seen graphically?
phonocardiogram
57
T/F: electrocardiograms give timing of cardiac events
true
58
what is a pansystolic murmur?
a murmur all throughout the systolic period; turbulent blood flow and can't even hear S1 and S2
59
what causes S1?
MV/TV closure
60
what causes S3?
early diastolic filling
60
what causes S2?
AoV/PV closure
61
what causes S4?
late diastolic filling
62
is S1 or S2 louder at the apex?
S1 > S2
63
is S1 or S2 louder at the base of the heart?
S2 > S1
64
why might heart sounds be lower than expected?
Obesity
– Fluid accumulation– pleural or pericardial
– Myocardial failure (reduced contractility)
– Mass lesion (diaphragmatic hernia)
65
why might heart sounds be louder than expected
- increased sympathetic tone
- hypertension (systemic or pulmonary)
66
what is the normal dog HR?
70-150
67
what is the normal cat HR?
140-220
68
what is the normal cow HR?
45-70
69
what is the normal horse HR?
30-50
70
if a heart rate is irregular, what are the 2 ways it can be irregular?
- regular irregular: sinus arrhythmia
- irregularly irregular: atrial fibrillation (shoes in dryer)
71
gallop sound
diastolic sounds associated with ventricular filling (something being added to lub/dub- when is that timing)
72
clicks
- extra sound
mid-systolic event usually related to valve prolapse
NOT a gallop- if hearing S1/S2 and then a sound after S2 before S1, that is diastolic (gallop)
if between S1 and S2, then that is systolic: this is a click: lub click dub lub click dub = sound is in BETWEEN S1 and S2
73
splitting
- S1 and S2 sounds are the fusion of 2 valves closing
- separation (MV then TV or AoV then PV) causes splitting
some conditions cause pulmonary valve to take longer to close, etc- "lub... det det"
need early on appreciation, muddy/delayed 2nd heart sound
74
S3
vibrations during early diastolic filling: blood rushes in and the chamber vibrates and makes a sound
heard in a SA patient with high filling pressure (ex L atrium distended, mitral valve opens and blood rushes in)
if you heart S3, worry about advanced heart disease in a dog
lub dub dub, lub dub dub
see it occurring right after 2nd heart sound
75
S4
vibrations associated with late diastolic filling
usualyl chamber that is stiff- old cat/hypertension: ventricle tries to relax and bring blood in but it relaxes slowly = in order to get blood into be ejected, the atrial kick has to be vigorous and pushes blood in at the end of diastole
"duh lub-dub, duh lub-dub"
76
clicks are a diastolic or systolic event?
systolic event
related to mitral or tricuspid valve prolapse (it bends back as it closes and creates a sound)
77
split heart sounds
- sometimes only appreciated as normal heart sound lasting longer than expected
- other times clear double sound
- often related to respiration (prolongation of P2 with right sided filling)
78
what is a heart murmur?
prolonged audible vibration during a normally silent period of cardiac cycle
79
when do murmur vibrations become audible?
when blood flow becomes turbulent
Increased velocity
– Decreased viscosity
– Flow into a large receiving chamber
80
description of heart murmurs
- location: point of maximal intensity (PMI): helps localize to specific valve areas
- timing
- duration
- intensity
- radiation
81
timing of heart murmurs
systolic, diastolic, continuous, to and fro
82
duration of heart murmurs
- protosystolic: early
- mesosystolic: mid
- telesystolic: late
- holosystolic: throughout phase (ex holodiastolic)
83
how are heart murmurs graded?
1/6 scale
84
grade 1/6 murmur
Nearly imperceptible, may be heard with very careful auscultation in a quiet environment; always focal
85
if you hear a "thrill" while palpating the heart, what automatic murmur grade does that get?
grade 5
86
if you lift your stethoscope 1cm off the surface and still hear a murmur, what automatic grade does taht get?
grade 6
87
grade 2/6 murmur
Heard readily but very soft; always focal
88
grade 3/6 murmur
Heard readily, moderate intensity; usually regional (can be heard in several auscultatory regions)
89
grade 4/6 murmur
Heard readily, loud, and usually radiates widely (can be heard in most or all auscultatory regions of the
heart), but without a palpable thrill
90
grade 5/6 murmur
Heard readily, loud, and associated with a precordial thrill, but the murmur is not heard with the
stethoscope lifted off the surface of the thorax
91
continuous murmur
same sound quality, variable intesnsity, just a whoosing noise
92
to and fro murmur
separate systolic and diastolic murmurs: windshield wipers
93
if the murmur is loudest at the left apex, what are your differentials?
– Systolic: mitral dysplasia, secondary mitral regurgitation
– Diastolic: mitral stenosis, aortic insufficiency
94
if the murmur is loudest at the left base, what are your differentials?
– Systolic: pulmonary or aortic stenosis, functional/innocent
– Diastolic: pulmonary or aortic insufficiency
– Continuous: patent ductus, arteriovenous fistulae
95
if the murmur is loudest at the right caudal heart, what are your differentials?
– Systolic: tricuspid dysplasia, VSD
– Diastolic: tricuspid stenosis
96
nonpathologic vs pathologic heart murmurs
nonpathologic: structural cardiovascular disease is absent
pathologic murmurs: structural cardiovascular lesion is present
97
non-pathological murmurs can be divided into what 2 categories?
1. functional murmur: no structural heart disease is detected, and there is a plausible physiologic explanation for the murmur (ex: anemia)
2. innocent murmur: no structural heart dz detected, no obvious physiologic explanation for murmur identified
98
what are the 6 qualifications that suggest an innocent murmur?
1. sensitive: changes with position/respiration
2. short duration: protosystolic
3. single: no associated clicks/gallops
4. small: limited to a small area, does not radiate
5. soft: low amplitude
6. systolic: limited to systole
99
innocent heart murmurs
* Heard often in small animal medicine
* Genesis remains uncertain
* If the murmur fits the 6 S’s –
– Recheck auscultation as animal grows
– Consider echocardiogram if persistent at > 6 months; increasing
intensity; or other signs develop
* If murmur does not comply with 6 S’s –
– Consider additional diagnostics now
100
friction rubs
* Scratching sounds that indicate friction/grating
between the two pericardial layers
* Heard most often in large animals with
inflammatory pericarditis
* Often confused with a murmur, but classically has
3 components that are out of phase to the heart
sounds
101
stridor
vibratory sound produced by narrowed large air passages, usually worse during INSPIRATION
usually reflects large airway obstruction (larynx, trachea)
102
stertor
harsh, snoring sound, usually inspiratory. typically related to soft palate obstruction or secretions in the upper airway
103
wheezes
reflect small airway collapse, usually expiratory and high pitched
104
crackles
harsh, popping sounds related to rapid opening of collapsed airways or alveoli
usually more inspiratory
