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Internal Medicine Diagnostics-Thoracic Cavity

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Internal Medicine Diagnostics-Thoracic Cavity Internal Medicine Diagnostics-Thoracic Cavity Sheila M. McGuirk, D. V.M., M.Sc. Department of Veterinary Physiology and Pharmacology College of Veterinary Medicine The Ohio State University Columbus, Ohio 432 JO The most valuable tools of the trained veterinarian are the tic evaluation is based in part on the acoustic accuracy of the ability to perform a complete physical examination, inter­ stethoscope. However, the acoustics of any stethoscope will pret the findings, make some logical conclusions based on reflect the acoustics of the human ear when it is worn. 1 The these findings, and design a course of therapy to return the diaphragm of the stethoscope amplifies high frequency patient to normal function. The successful diagnostician sounds while attenuating low frequencies. 2 Poor quality or may perfect his clinical exam by perfecting his ability to cracked diaphragms will attenuate all frequencies. The bell is interpret what he finds or by employing more sensitive used to amplify low frequency sounds. The shallow, bowl­ diagnostic tools in order to gain more specificity in defining shaped bells have no useful high frequency response at all. and treating the problems he sees. Diagnosis of problems in The tu bing of the currently available stethoscopes are either the thoracic cavity are often overlooked. More often than single or double. Although the single tube is more compact not the problem stems from the failure to perform a good and subject to less extraneous noise, it is subject to examination of the chest. Avoidance of the thoracic cavity, irregular distortion patterns and suffers from considerable however, is the result of confusion over i~terpretation of loss of output at high frequencies. The double tube stetho­ what is seen and heard. The purpose of this paper is to scopes amplify high frequency sounds but they are often review some of th~ diagnostic methods used in physical more cumbersome to use. The stethoscope with fused double examination of the thoracic cavity. The focus will be on tubes has the same acoustical advantage of the double tubes auscultation since this is the most useful diagnostic while being more compact. With tubes of increasing length procedure every veterinarian can perform. both high and low frequency sounds will become progress­ 0 "'O Physical examination of the thorax begins with inspection ively more damped. The earpieces should be tight fitting to (D of the animal. At this time a decision can oftentimes be made avoid air leaks and admission of extraneous noise. Only ~ ~ whether the problem is thoracic or abdominal. Hallmarks of when one auscults the thoracic cavity in relative quiet can the (") (D disease in the chest are: labored breathing (prolonged trained ear distinguish sounds generated in the chest from 00 00 inspiration or expiration), marked thoracic or abdominal extraneous noise. 0-...... 00 excursions with each breath, flared nostrils, or open mouth The acoustic system is made up of: (I) the source ,-+- '"i breathing. Cardiovascular disease may be heralded by producing vibrations within the body which are transmitted ~ distended jugular veins, abnormal jugular pulsations or through tissue to the wall of the chest; (2) the stethoscope, ~...... edema. Palpation of the thoracic cage may reveal thrills (in which receives vibrations at the surface of the skin and 0p the cardiac dullness area), friction rubs, fractured ribs, or transmits them to the ear; and (3) the ear, itself, which subcutaneous emphysema. permits one to hear vibrations as sounds. Auscultation is the most important tool used in the By auscultating the cardiac area of either the left or right diagnosis of diseases of the chest. The majority of clinical side, one should always hear 2 distinct sounds for each car­ conditions involving the chest can be diagnosed by careful diac cycle. The normal range for the heart rate of the cow is auscultation alone. Under the best circumstances other between 60 and 80 beats per minute. The first heart sound dianostic procedures (ECG, radiograph, ultrasound, (S 1) occurs at the onset of ventricular contraction (systole) endoscopy) can be implemented for confirmation of the and is produced basically by the closure of the tricuspid and diagnosis but the bovine practitioner must rely on the stetho­ mitral (AV) valves and partially by the opening of the scope alone. Besides being the most useful diagnostic pulmonic and aortic (semilunar) valves. 3 procedure available, auscultation takes a small amount of The second heart sound (S2) follows S 1 and marks the end time, it yields a great amount of information, and it is cost of systole. It is generated mainly by closure of the semilunar effective. The drawbacks are few. Skill is required for inter­ valves but the opening of the A-V valves may also contribute pretation of information gained by using the stethoscope to genesis of the sound. This sound may be variably split and communication is often difficult because of confusing with respiration in the normal animal. Consistent splitting of terminology, which is especially true of lung sounds. the S 2 with every cardiac cycle may be suggestive of pulmo­ The requirements for productive auscultation are a good nary hypertension, the most common cause of the latter in quality, comfortable stethoscope. The accuracy of diagnos- cattle being hypoxia (high altitude or brisket disease). APRIL, 1983 69 The first heart sound is louder, longer, and lower pitched are rare in cattle but may be associated with valvular than S 2 and is heard best at the apex of the heart. The second endocarditis. In cases such as the latter, the diastolic heart sound is heard best at the base of the heart, the murmur is also accompanied by a systolic murmur ("to and location of which is reached by forcing the stethoscope be­ fro murmur"). In the young calf a continuous (systolic and tween the elbow and thorax and moving dorsally up under diastolic) murmur is the sign of a patent ductus arteriosus. (Q) the triceps. The intensity of both sounds depends on the n The murmurs or sounds which occur with pericarditis 0 vigor of ventricular contraction, valve structure, chest (traumatic) are distinctive in cattle. The "washing machine" '"a '-< conformation, and type of disease process (if any) present. or splashing sounds can be heard at the left base and at the ......'"i (JQ In addition to S 1 and S 2, the astute practitioner may hear apex during systole and diastole. Distinct cardiac sounds are g S 4, which precedes S 1, or S3, which follows S 2. The fourth often muffled by the pericardia) effusion. heart sound is a low frequency sound generated by atrial Cardiac arrhythmias in cattle are rarely primary signs of contraction, and heard best at the heart base. It may be cardiac disease. They usually occur with gastrointestinal timed very closely to S 1, giving a sound which is difficult to disease (atrial fibrillation, bradycardia) electrolyte disorders distinguish from a split S 1. The third heart sound is also a (atrial or ventricular premature beats), excitement, viral low frequency sound, which is heard best at the apex of the infection (myocarditis), or other disorders characterized by heart, and is generated by ventricular filling. •Auscultation of severe metabolic derangement (hypocalcemia, hypercalce­ 3 distinct cardiac sounds is termed a gallop rhythm. A mia). The arrhythmias usually resolve with correction of the presystolic gallop (S 4-SrS2) is normal in cattle. The primary condition and therefore require no specific therapy. significance of a protodiastolic gallop (S 1-S 2-S 3) is The atrial arrhythmias which are present in adult questionable if no other signs of heart disease are present. lymphosarcoma usually indicate specific involvement of the Interpretation of cardiac murmurs is relatively easy if the heart. practitioner is familiar with the origin of heart sounds, can Auscultation of the lungs can also be rewarding in the locate the position (apex vs. base) and side (left vs. right) information that it yields. However, interpretation of lung where the murmur is loudest, and knows the age and medical sounds and the confusing terminology used to describe lung history of the animal. Congenital murmurs, the most sounds often leads to a reluctance to complete this part of common of which is the ventricular septal defect (VSD) in the physical exam. The bovine practitioner must cultivate cattle, are heard in young animals, whereas acquired his ability to auscultate since radiography and the other murmurs occur most commonly in adults. Acquired more sophisticated diagnostic tools of the small animal murmurs are commonly caused by vegetative endocarditis, veterinarian are not always practical. The practitioner .§ usually involve the tricuspid valve, and occur in cows with begins his examination of the lungs by distinguishing nor- g intermittent fever, and other signs of a persistent infection. ma! breath sounds from the added (adventitious) sounds ~ Cardiac murmurs which occur between S and S are generated by pathologic processes. Evaluation of lung (") 1 2 (D 00 systolic murmurs. In cattle early systolic low intensity sounds is best during deep respiratory efforts, especially 00 murmurs at the left heart base are not uncommon and are when optimal quiet is not possible. Deep breathing can be 0........ 00 ,-+- considered "functional" or ejection sounds. The functional transiently produced by holding off the nostrils for a minute '"i murmur is often associated with fever, excitement, or and then ausculting the chest immediately after release. Sus­ ~ anemia. The defects of pulmonic stenosis (PS) and aortic tained deep respiratory efforts can be produced by putting a ~...... stenos is (AS) may produce a similar murmur at the left heart plastic bag loosely over the muzzle of the cow, thereby 0p base but are rare in cattle unless they are caused by valvular forcing the cow to rebreathe her expired air.
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