Follow Your Heart: The Essential Cardiovascular Physical Examination PDF

Follow Your Heart: The Essential Cardiovascular Physical Examination Hillary Hammond, DVM, MS, DACVIM (Cardiology)  Mucous membranes Jugular Veins Cardiac Auscultation Cardiopulmonary Exam Respiratory Auscultation...

Follow Your Heart: The Essential Cardiovascular Physical Examination Hillary Hammond, DVM, MS, DACVIM (Cardiology)  Mucous membranes Jugular Veins Cardiac Auscultation Cardiopulmonary Exam Respiratory Auscultation Arterial Pulses Abnormal Fluid Accumulation Mucous Membranes Estimate of adequacy of peripheral perfusion and tissue oxygenation Most often ORAL – gums and tongue Capillary Refill Time (CRT) Normal: < 2 sec Prolonged: decreased cardiac output Mucous Membranes Color Normal pink Pallor Hyperemic, injected Cyanosis Icteric Petechiation Mucous Membranes Color Normal pink Pallor Due to anemia, peripheral vasoconstriction, reduced tissue perfusion or combo Ex: shock, dehydration, heart failure, cardiac tamponade, PTE Hyperemic, injected Cyanosis Icteric Petechiation Mucous Membranes Color Normal pink Pallor Hyperemic, injected Breed variation High PCV Peripheral vasodilation Activity, excitement, septic shock Cyanosis Icteric Petechiation Mucous Membranes Color Normal pink Pallor Hyperemic, injected Cyanosis Bluish discoloration Increase in deoxygenated hemoglobin >5 g/dL deoxyhemoglobin 1/3 up neck) Increased venous pressure Volume overload, R- CHF, CrVC obstruction Cat with PS and R CHF Cow with brisket disease/severe PH (note JV distension and brisket edema)  Jugular Pulsation and Distension - Abnormal Pulsation Variations in volume due to arrhythmia Atrial fibrillation Atrioventricular block Increase pressures in RIGHT heart Tricuspid regurgitation Pulmonary valve stenosis Horse with Afib Dog with TVD, PS, and R CHF Cardiac Auscultation - Stethoscope Ear pieces Binaurals Tubing Bell Diaphragm Where to Auscultate- Dogs Valve Areas: Mitral: at and dorsal to left apical Great Vessels LEFT impulse Aortic: craniodorsal to MV, second sound is loudest Pulmonary: one ICS cranioventral to AoV 3 4 5 Other locations P AM Over great vessels: left craniodorsal thorax Where to Auscultate- Dogs Valve Areas: Tricuspid: on right, just cranial to RIGHT MV Other locations Right sternal edge Thoracic inlet Where to Auscultate- Large Animals Great Vessels LEFT Where to Auscultate – Cats/Ferrets/Birds Auscultate along each side of sternum/keel – apically and cranially Where to Auscultate - Reptiles Cardiac Auscultation – Rate/Rhythm Dog Cat Horse 60-160 bpm 140-240 bpm 28-44 bpm Count # of beats over 15 seconds and multiple by 4 = beats per minute (BPM) Is the HR appropriate for patient? activity level? sympathetic drive? Is it too fast? Tachycardia Is it too slow? Bradycardia Is the rhythm regular or irregular?  Cardiac Auscultation – Heart Sounds S1 aka “Lub” Closure of the atrioventricular (mitral, tricuspid) valves Lower pitch Normal in all animals S2 aka “Dub” Closure of the semilunar (aortic, pulmonary) valves Higher pitch Normal in all animals  Cardiac Auscultation – Heart Sounds S3 Rapid ventricular filling due to poorly compliant ventricle Early diastole Pathologic in SA (gallop), +/- normal in LA S4 Atrial contraction (“kick”),abnormal ventricular relaxation Late diastole Pathologic in SA (gallop), +/- normal in LA Cardiac Auscultation- Cardiac Murmur Definition: prolonged audible vibrations heard during a normally quiet period of cardiac cycle General Causes: High velocity/turbulent flow Ejection of large stroke volume Decreased blood viscosity (anemia) Narrow region → large area Physiologic vs Pathologic Cardiac Auscultation – Murmur Description Intensity Location Timing Murmur – Intensity or Grade Grade Description (out of VI) I Low-intensity murmur, heard only in a quiet environment after careful auscultation over a localized cardiac area II Low-intensity murmur, heard immediately when auscultating over point of maximal intensity, quieter than S1/S2 III Moderate intensity murmur, as loud as S1/S2, easily localized IV High-intensity murmur, radiates to several areas of heart, no precordial thrill V High-intensity murmur with a palpable precordial thrill VI High-intensity murmur with a palpable precordial thrill, can be heard even without stethoscope Murmur - Location Base Left Aortic Valve Pulmonary Valve Murmur - Location Apex Left: Mitral valve Right Tricuspid Valve S1 S2  Common Cardiac Murmurs – Timing Systolic Diastolic Mitral regurgitation Aortic insufficiency Tricuspid regurgitation Pulmonary Subaortic/Aortic stenosis insufficiency Mitral stenosis Pulmonary valve stenosis Ventricular septal defect To-and-Fro Aortic valve stenosis Continuous AND aortic insufficiency Patent Ductus Pulmonary valve Arteriosus (PDA) stenosis AND pulmonary insufficiency Murmurs – Mitral Regurgitation Common in dogs, cats, horses, and other species Timing: Systolic PMI: Left apex or mitral area Lesions Associated: Valvular degeneration in dogs, horses Any LV dilation, hypertrophy, or fibrosis that alters valve support Systolic anterior motion of MV Mitral valve dysplasia Infective endocarditis Respiratory Auscultation Covered in another lecture…. Arterial Pulse Palpation Dog, cat, goat, sheep: Horse: Cow: femoral artery facial or digital arteries coccygeal artery Arterial Pulse Palpation Influenced by: Ventricular stroke volume Ejection velocity Arterial compliance Vascular resistance Heart Rate BCS Quality of pulse palpated related to “pulse pressure” Difference between systolic and diastolic pressure *You CANNOT determine BP from palpating arterial pulse* Listen and feel: “strong and synchronous” Arterial Pulse Palpation Hyperkinetic Pulses Stronger than normal “Bounding” or “Waterhammer” Widened pulse pressure Increase in systolic pressure Greater fall in diastolic pressure Examples PDA Aortic Insufficiency Marked bradycardia Arterial Pulse Palpation Hypokinetic Pulses Weaker than normal “Pulsus Parvus” Reduced pulse pressure PP Examples Severe myocardial PP dysfunction LVOT obstruction Tachycardia  Arterial Pulse Palpation Pulse Deficit Variability between arterial pulse palpation and cardiac contractions Heart beats before adequate ventricular filling to create palpable pulse Examples: Premature beats Atrial fibrillation Ventricular tachyarrhythmia *Perform an ECG* Arterial Pulse Palpation Abnormal Fluid – Abdomen Abdominal distension Palpable fluid wave Hepatomegaly Ascites Right-sided congestive heart failure Biventricular heart failure Fluid analysis Abnormal Fluid – Abdomen Abnormal Fluid – Pericardial, Pleural Use other aspects of PE Pleural Effusion Respiratory Rate/Effort Pericardial Heart rate/rhythm Pulses TFAST Abnormal Fluid – Peripheral Edema Take Home Points Mucous membranes provide a crude estimate of perfusion and tissue oxygenation and be able to provide differentials for various colors of MM. Jugular veins are the window to the right heart and an increase in jugular venous distension/pulsation indicates a possible lesion on the right side of the heart or obstruction to venous flow. Know what physiologically is occurring with each heart sound (S1,S2,S3,S4) and which are normally auscultable in small animals and large animals. Be able to predict timing and PMI for murmurs associated with most common congenital and acquired heart diseases. Pulse quality is determined by pulse pressure which is the difference between systolic and diastolic pressures.  Questions? Email: [email protected] Don’t forget about pre-lab assignment due 1/21/25 and to bring your stethoscope to lab!