The History and Physical Examination

Chapter 1 The History and Physical Examination

Rebecca E. Gompf

INTRODUCTION

Despite the technical nature of many cardiovascular diagnostics, such as electrocardiography and echocardiography, the history and physical examination remain the most crucial steps in establishing the correct diagnosis. Findings from a careful history and physical examination prompt the clinician to the probability or presence of heart disease. Results of the cardiovascular physical examination will usually allow the clinician to make a tentative diagnosis or formulate a specific differential diagnosis. The history and physical examination also provide important information regarding the stage of heart disease present, which may significantly impact therapy.

• A good history and physical exam are invaluable in making a diagnosis of heart disease and helping to differentiate heart disease from pulmonary disease.

• Besides helping to make the diagnosis, a good history and physical exam help to tell the extent of the problem, how well the animal is responding to previous therapy, if the owner is able to medicate the animal consistently, and if other medical problems are present.

Key Point

Clinicians should do a thorough history and physical exam in order to properly diagnose and treat an animal with heart disease.

MEDICAL HISTORY

Signalment

Age

Young animals usually present with congenital diseases (e.g., patent ductus arteriosus [PDA]), whereas older animals usually present with acquired diseases, such as degenerative diseases (e.g., mitral and tricuspid regurgitations) or neoplastic diseases (e.g., heart base tumor). Exceptions can occur because cardiomyopathies can occur in young dogs and cats (aged 6 months or younger), and older dogs can have congenital heart defects that were not diagnosed when they were young (e.g., PDA, atrial septal defect). Also, cardiac disease in older animals can be modified or affected by other concurrent disease processes (e.g., collapsing trachea, renal or liver disease).

Breed

Certain cardiac defects are more common in some breeds of animals; however there can be a regional difference in the rate of occurrence of cardiac problems. See Appendix for a summary of some of the cardiac defects found in certain breeds of dogs and cats.

Sex

Males are more susceptible to certain cardiac diseases (e.g., male cocker spaniels to endocardiosis of the mitral valve, and large-breed males to dilated cardiomyopathy). However, sick sinus syndrome occurs in the female miniature schnauzer and PDA is more common in females than in males.

Weight

The animal’s weight influences several aspects of treatment including the dose of cardiac medication to use, evaluation of the response to diuretic medication, and the monitoring of cardiac cachexia. A Pickwickian syndrome (characterized by severe obesity, somnolence, and hypoventilation) can occur in an animal that is so obese that its ability to breathe is restricted.

Utilization of the Animal

It is important to know how an animal is going to be used when giving a long term prognosis for a cardiac disease. For example, hunting dogs with severe heartworm disease may not be able to hunt again after treatment. Also, some animals with congenital heart defects may have normal life spans and may make good pets; however, they should not be used for breeding purposes, because the defect could be perpetuated.

Key Point

The age, breed, and sex of the animal may help the clinician to make an accurate diagnosis; however, there are always exceptions to every rule, so a clinician should not ignore the fact that an animal could have an atypical problem for its age, breed, or sex.

History

• A good history will establish the presence of a cardiac problem, help to differentiate between cardiac and respiratory problems, and help to monitor the course of the disease and the response to therapy. It must be done carefully to prevent an owner from giving a misleading history.

• It includes several key questions such as the reason the animal is being presented, the problems noted by the owner, the onset and duration of the problem(s), the progression of the disease, any known exposure to infectious diseases, vaccination history, any current medications the animal is receiving, the animal’s response to any medications that have been given, and the owner’s ability to give the medication(s).

• It will also define the animal’s attitude and behavior by asking if the animal is listless and depressed or alert and playful. Does the animal tire easily with exercise?

• It covers the family history of the siblings and parents, especially if congenital disease is present in the patient.

• It will ask about the health of other pets in the household.

• It includes the results of previous tests done on the patient.

• It covers other relevant information that may help to identify the patient’s problem(s), such as what and how much is being fed and the patient’s appetite and water consumption. How frequently is the animal urinating, and does it have any diarrhea? Does the patient have any vomiting or regurgitation? Has the patient had any seizures or syncopal episodes? What is the patient’s reproductive status? Does the patient have any lameness or paresis? Is the patient coughing, sneezing, or having difficulty breathing? Has the patient had any previous trauma? Where is the animal housed (e.g., indoors, outdoors, fenced-in yard)?

• It includes information about other diseases such as hyperthyroidism, chronic renal disease, respiratory diseases, or other diseases that can also affect the heart or can affect how the animal’s heart disease is treated.

• Once a problem is identified, more specific questions can be asked such as the character of a cough, when the cough occurs, and stimuli evoking the cough.

• Common presenting complaints for cardiac disease include dyspnea or tachypnea, coughing, exercise intolerance, syncope, abdominal swelling, cyanosis, anorexia or decreased appetite, and poor growth or performance.

• Other symptoms can be associated with cardiovascular disease. Polydipsia and polyuria are common in animals on diuretics or that have a concurrent disease (e.g., renal disease), whereas oliguria occurs with severe left-heart failure. Hemoglobinuria is found with the postcaval syndrome of heartworm disease.

• Cardiac drugs such as digitalis, quinidine, and procainamide can cause vomiting and diarrhea. Regurgitation occurs with congenital vascular ring anomalies. Right-heart failure can cause intestinal edema and a protein-losing enteropathy resulting in diarrhea. Cats with cardiomyopathy can develop hemorrhagic enteritis secondary to thromboembolism of the gastric or mesenteric arteries.

Key Point

A good history will uncover all of the animal’s symptoms and problems whether they are due to a cardiac problem or to another concurrent problem. Also, by the end of a good history, an astute clinician will have a good idea as to the potential causes of the animal’s problems.

SPECIFIC SYMPTOMS

Coughing

• Coughing is the most common complaint in dogs with significant heart disease, but cats rarely cough even when they have an enlarged left atrium.

• Coughing is a sudden, forced expiration and is a normal defense mechanism to clear debris from the tracheobronchial tree. It can originate from many different areas such as the pharynx, trachea, bronchi, bronchioli, pleura, pericardium, and diaphragm.

• A cardiac cough can be difficult to differentiate from a respiratory cough. Table 1-1 lists some of the characteristic coughs and their associated causes.

• Dogs with pulmonary edema often have an acute onset of coughing that progresses rapidly to a severe cough and dyspnea. These coughs are usually soft.

• Dogs with chronic heart disease usually have mild, intermittent coughs. They may also have nocturnal dyspnea, coughing, and restlessness. Their coughs tend to be harsh and lower pitched.

• Dogs with fulminant left-heart failure may have pink foam in their mouth and nose and be dyspneic, but they may or may not be coughing.

• Dogs with a loud, harsh, dry cough of sudden onset followed by a nonproductive gag commonly have tracheobronchitis.

• Dogs with a honking, high-pitched cough often have a collapsing trachea and/or collapsed bronchi.

• Small breeds of dogs with large airway disease will have a chronic, paroxysmal cough that is hard, loud, and honking, and usually occurs with excitement.

• Dogs that cough after drinking may have cardiac disease, collapsing trachea, chronic tracheitis, tracheobronchitis, laryngeal problems, or other causes of dysphagia.

• Dog that cough without an inciting factor may have cardiac, pulmonary, or extrapulmonary disease.

• Dogs that cough after eating have pharyngeal dysphagia, megaesophagus, vascular ring anomalies, esophageal diverticula, esophageal foreign bodies, or esophageal tumors.

• It is unusual for cats to cough with congestive heart failure; however, they will cough with heartworm disease. If the clinician compresses the cat’s trachea and the cat has a prolonged bout of coughing, then coughing is likely to be part of the cat’s problem.

Key Point

It is important to distinguish between a cough due to cardiac disease versus one due to respiratory disease. The history can be the first step in differentiating between the two major causes of coughing.

Table 1-1 Characteristics of Coughs and Their Associated Causes in Dogs and Cats

Type of Cough	Causes
Acute cough	Tonsillitis, pharyngitis, tracheobronchitis, acutebronchitis, pleuritis, acute left heart failure (dogs)
Chronic cough	Right or left heart disease, heartworms, enlarged left atrium compressing the left mainstem bronchus (dog only), pulmonary neoplasia, asthma (cat only), chronic respiratory problem, chronic bronchitis (dog only)
Acute onset, soft that rapidly becomes worse in dogs with dyspnea	Pulmonary edema
Mild, intermittent cough, harsh, low pitched in dogs	Chronic heart disease
Loud, harsh, dry, sudden onset followed by gag in dogs	Tracheobronchitis
Honking, high-pitched in dogs	Collapsing trachea or bronchi
Chronic, paroxysmal, loud, honking with excitement in dogs	Large airway disease
Cough after drinking in dogs	Cardiac disease, collapsing trachea, chronic tracheitis, tracheobronchitis, laryngeal paralysis, dysphagia
Cough after eating in dogs	Pharyngeal dysfunction, megaesophagus, vascular ring anomalies, esophageal diverticula, esophageal foreign bodies, esophageal tumors
Cough without an inciting factor	Cardiac, pulmonary, or extrapulmonary disease

Dyspnea

• Dyspnea is difficult, labored, or painful breathing. It is usually preceded by tachypnea (an increased rate of breathing), which owners may miss. It is a good idea to have the owner of a cardiac patient learn to count his or her pet’s respiratory rate at rest. The respiratory rate should be less than 30 per minute in a dog at rest, and if it goes over 50 per minute, then the dog has tachypnea.

• Dyspnea will occur whenever anything increases the amount of air that must be breathed by the animal. Box 1-1 lists the problems that can cause dyspnea.

• The most common cardiac cause of dyspnea in the dog is left-heart failure causing pulmonary edema. The most common cardiac cause of dyspnea in the cat is right-heart failure causing pleural effusion or left-heart failure causing pulmonary edema.

• Dyspnea can be accompanied in cardiac patients by stridor, which is a harsh, high-pitched respiratory sound. Other sounds include rhonchi, which sound like dry, coarse crackles. Also, dyspnea can be accompanied by wheezing, which is more typical of respiratory problems than cardiac problems.

• Table 1-2 lists the different types of dyspnea and the problems associated with each type.

• Acute dyspnea is usually caused by pulmonary edema (cardiac and noncardiac), severe pneumonia, airway obstruction, pneumothorax, or pulmonary embolism.

• Chronic, progressive dyspnea is caused by right-heart failure with ascites and/or pleural effusion, pericardial diseases, bronchial disease, lung diseases such as emphysema, pleural effusions, progressive anemia, and primary or secondary pulmonary neoplasia.

• Dyspnea at rest occurs with pneumothorax, pulmonary embolism, and severe left- or right-heart failure.

• Exertional dyspnea occurs after or during activity and can be associated with heart diseases, such as dilated cardiomyopathy, when the animal goes into heart failure. It can also be associated with chronic, obstructive lung disease.

• Expiratory dyspnea is prolonged and labored expiration and is due to lower respiratory tract obstruction or disease.

• Inspiratory dyspnea is prolonged and labored inspiration and is due to upper airway obstruction.

• Mixed dyspnea is due to severe pulmonary edema caused by left-heart failure or severe pneumonia.

• Orthopnea means that the dyspnea occurs when the animal lies down but not when it is standing. It is associated with severe pulmonary edema, pleural effusion, pericardial effusion, pneumothorax, diaphragmatic hernia, and severe respiratory problems.

• Paroxysmal dyspnea means that the dyspnea comes and goes. It can be associated with arrhythmias that cause either bradycardia or tachycardia.

• Simple dyspnea, or polypnea, is an increased rate of respiration due to fever, fear, pain, or excitement.

• Cats with severe hyperthyroidism can also be dyspneic.

• Dyspnea that improves when treated with diuretics and angiotensin-converting enzyme inhibitors plus or minus digoxin is suggestive of left-heart failure as the cause of the dyspnea.

• Dyspnea that improves when treated with bronchodilators, antibiotics, or steroids is suggestive of respiratory disease as the cause of the dyspnea.

Key Point

Dyspnea is a sign of significant cardiac, respiratory, or other systemic problems. It requires immediate diagnostic tests to identify the cause of the dyspnea so that specific therapy can be started. However, all tests should be done with minimal stress to the animal as these patients are very fragile and could die with stress.

Table 1-2 Types of Dyspnea and Their Associated Diseases or Problems

Type of Dyspnea	Disease or Problem
Acute dyspnea	Pulmonary edema (cardiogenic and noncardiogenic), severe pneumonia, airway obstruction, pneumothorax, pulmonary embolism
Chronic, progressive dyspnea	Right heart failure with ascites and/or pleural effusion, pericardial diseases, bronchial disease, lung diseases (e.g., emphysema), pleural effusions, progressive anemia, primary and secondary neoplasia
Dyspnea at rest	Pneumothorax, pulmonary embolism, severe left or right heart failure
Exertional dyspnea	Heart disease (e.g., dilated cardiomyopathy) or chronic obstructive lung disease
Expiratory dyspnea	Lower respiratory tract obstruction or disease
Inspiratory dyspnea	Upper airway obstruction
Mixed dyspnea	Pulmonary edema due to left heart failure or severe pneumonia
Orthopnea	Severe pulmonary edema, pericardial effusion, pleural effusion, diaphragmatic hernia, pneumothorax, severe pulmonary disease
Paroxysmal dyspnea	Arrhythmias (e.g., bradycardia or tachycardia)
Simple dyspnea	Fever, fear, pain, or excitement

Hemoptysis

• Hemoptysis is coughing up of blood. It is uncommon in animals, as they usually swallow their sputum. It is a sign of very severe pulmonary disease.

• The causes of hemoptysis are listed in Box 1-2.

• Cardiac causes of hemoptysis include severe pulmonary edema (e.g., ruptured chordae tendineae) and severe heartworm disease, usually with pulmonary embolism.

Key Point

Hemoptysis is a sign of a very serious underlying abnormality in the lungs, which may be caused by either a severe cardiac or respiratory problem.

Syncope

• Syncope is a loss of consciousness due to inadequate cerebral blood flow. It can reoccur and is usually brief.

• Syncope can be hard to differentiate from seizures. Animals usually fall over suddenly, get back up quickly, and are normal before and after the syncopal episode.

• Box 1-3 lists the causes of syncope in dogs and cats.

• In a dog with no other cardiac problems, syncope may be associated with severe bradycardias (e.g., third degree heart block or sick sinus syndrome), or with marked sustained tachycardias (e.g., atrial or ventricular tachycardias), which are usually paroxysmal (i.e., they come and go).

• Small dogs with chronic, severe mitral regurgitation that cough when they get excited can have syncopal episodes.

• Dogs with severe subaortic stenosis, pulmonic stenosis, pulmonary hypertension, or tetralogy of Fallot can have arrhythmias associated with their ventricular hypertrophy and myocardial hypoxia. Syncope can also occur in cats with severe hypertrophic cardiomyopathy.

• Animals with poor cardiac output due to dilated cardiomyopathy can have syncope, especially if they also have arrhythmias such as atrial fibrillation or ventricular premature beats that further reduce their cardiac output.

• Vasodilators, especially arterial dilators, can result in systemic hypotension, which can cause syncope.

Key Point

Syncope must be distinguished from seizures by careful history and physical examination. Having the owner videotape an episode can also help the clinician to distinguish between the two. Further tests such as Holter or event monitoring may be necessary to determine if an arrhythmia is causing the syncope.

Weakness and Exercise Intolerance

• Weakness and exercise intolerance are nonspecific signs of heart disease. Many diseases such as severe anemia, systemic diseases, metabolic diseases (e.g., hyperadrenocorticism), drug toxicities, and severe respiratory diseases can cause these signs. See Box 1-4 for causes of weakness and exercise intolerance.

• Because most animals do not exercise very hard, weakness and exercise intolerance are uncommon presenting complaints. Some owners think that their animal is slowing down due to old age and not due to heart disease or other problems.

• Both complaints can be an early sign of decompensated heart failure, as the heart cannot pump enough blood to the muscles due to:

• Myocardial dysfunction (e.g., dilated cardiomyopathy or advanced mitral valve disease)

• Obstruction to left ventricular outflow (e.g., subaortic stenosis or hypertrophic obstructive cardiomyopathy)

• Inadequate ventricular filling (e.g., arrhythmias, pericardial diseases, hypertrophic cardiomyopathy)

• Decreased arterial oxygen (e.g., pulmonary edema or pleural effusion).

Key Point

It is important to distinguish between exercise intolerance due to heart disease versus other causes.

Ascites

• Ascites is an accumulation of fluid in the abdomen.

• Ascites caused by cardiac problems is either due to the right heart being unable to pump the blood presented to it or because of pericardial disease, in which the blood cannot get into the right heart. In either case the blood accumulates in the liver and spleen and causes congestion and increased venous pressure. Eventually fluid leaks out of the capsule of the liver causing the ascites.

• Ascites is seen more frequently with right-heart failure in dogs due to acquired diseases (e.g., tricuspid regurgitation due to endocardiosis, advanced heartworm disease, dilated cardiomyopathy, pericardial effusions, restrictive pericarditis) and congenital heart defects (e.g., tricuspid dysplasia, large ventricular septal defect, large atrial septal defect). See Figure 1-1 for an example of ascites and Box 1-5 for a list of causes of ascites in the dog.

• Ascites is less common in cats and is usually due to tricuspid dysplasia but occasionally can be seen with other problems such as dilated cardiomyopathy.

• Large amounts of ascites will put pressure on the diaphragm, resulting in tachypnea or dyspnea.

• Ascites associated with right-heart failure is usually a modified transudate and accumulates slowly.

Key Point

Decompensated heart diseases that result in ascites may not have an associated murmur (e.g., pericardial effusion, some dilated cardiomyopathies, heartworm disease). Thus, any time ascites occurs, right-heart failure must be included in the differential diagnosis.

Figure 1-1 Notice the severe ascites in this dog with right-heart failure due to severe pulmonic stenosis and severe tricuspid dysplasia.

Cyanosis

• Cyanosis is blue-tinged mucous membranes of the gums, tongue, eyes, ears, and so on and is associated most commonly with right-to-left shunting congenital heart defects. Occasionally it is seen with severe left-heart failure or severe respiratory disease. It is rarely seen with abnormal hemoglobin production.

• Cyanosis is a very insensitive way of detecting hypoxemia in dogs and cats because the oxygen saturation has to be very low to cause it and animals have darker mucous membranes, which makes cyanosis harder to detect until it is severe.

• Right-to-left shunting cardiac defects such as tetralogy of Fallot result in low oxygen saturation plus high deoxygenated hemoglobin levels, which make affected animals cyanotic. These patients also have polycythemia, and the increased number of red blood cells has increased amounts of reduced hemoglobin, which contributes to the cyanosis.

• Cyanosis gets worse with exercise because the peripheral vascular resistance will decrease while the pulmonary vascular pressure is unchanged so more deoxygenated venous blood will go systemically.

Key Point

Cyanosis is a very late finding in severe cardiac disease, except in right to left shunting congenital heart defects, and so it is an insensitive indicator of membrane oxygenation and cardiac function.

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Tags: Manual of Canine and Feline Cardiology

Aug 15, 2016 | Posted by admin in SMALL ANIMAL | Comments Off

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