|Reason for Visit||Decreased appetite, cough and labored breathing|
|Medications||Amoxicillin 500mg: 1 capsule q 12hrs|
Please review Athena's clinical history.
|Coughing||Coughing for two weeks|
|Respirations||Increased respiratory effort over the last 2 days|
|Exercise Tolerance||Refusing to go on normal walks|
|Sleep Patterns||Prefers to lay in sternal recumbency which is atypical|
|Weight Change (loss or gain)||None|
|Appetite||Has become very particular about food over the last 2 weeks|
|Usual Diet||Purina OM™, 4 cups per day|
|Change in urinary habits||None|
|Change in drinking habits||None|
|Other symptoms or signs||None|
Please review the results of Athena's physical exam.
|Mobility | Gait||Ambulating normally|
|Posture||Standing or sternally recumbent|
|Body Temperature||100.2 F|
|Arterial pulse - rate, regularity, intensity||Weak, irregular pulses with a rate of 180/min with pulse deficits|
|Respiratory Effort||Increased respiratory effort|
|Mucous Membranes - Color & CRT||Mildly pale|
|Jugular Venous Pulse & Pressure||No jugular distention|
Let's auscult Athena's heart & lungs.
Direct HR: 210 bpm
The CEG considers the following differential diagnosis as most likely (and why):
The patient's signalment (age and breed), along with the complaint of cough, respiratory distress, and an arrhythmia makes dilated cardiomyopathy the leading differential in this case. The patient's decreased appetite, altered exercise tolerance, and lethargy would be common findings in cases of congestive heart failure compared to many more benign causes of cough. Degenerative valve disease is less likely given the signalment and the lack of a significant heart murmur, however arrhythmias may often reduce the intensity of heart murmurs so valvular disease can not be completely excluded. The presence of the arrhythmia also leads us away from a diagnosis of primary respiratory disease, however we can not completely exclude the possibility of primary respiratory disease with an unrelated arrhythmia.
The CEG considers the following diagnostic tests as the highest priority:
The highest priority diagnostic test to help determine the etiology for the clinical signs was thoracic radiographs. Benefits of thoracic radiographs in Athena's case include assessment of the pulmonary vasculature and pulmonary parenchyma, along with assessment of the heart size. Because dilated cardiomyopathy is often accompanied by cardiac dilation, thoracic radiographs are often useful to detect the eccentric hypertrophy in symptomatic dogs. NT-proBNP assessment may add information in cases in which the radiographic findings are ambiguous (click here for the circulation article "Use of NT-proBNP in the Dog"). The electrocardiogram is equally critical to document the presence of supraventricular arrhythmias, ventricular arrhythmias, or a combination of the two. The type of arrhythmia present alters management protocols and level of risk for sudden cardiac death. Blood pressure measurement was strongly recommended to assess the degree of hypotension present and establish a baseline blood pressure that may be followed to guide acute therapy. The chemistry profile and urinalysis are important to evaluate renal function as we suspect dilated cardiomyopathy and congestive heart failure account for the clinical signs. The presence of concurrent renal disease complicates management of congestive heart failure. The complete blood count, although not 100% specific, may provide insight into the presence of infectious or inflammatory pulmonary disease. Echocardiography is required for the confirmation of dilated cardiomyopathy.
Please review Athena's thoracic radiographs
Please review Athena's lab results
|BUN||24 mg/dL, Normal: 5 - 29 mg/dL|
|Creatinine||1.7 mg/dL, Normal: 2.1 mg/dL|
|Sodium||140 mmol/L, Normal:138 - 154 mmol/L|
|Potassium||3.8 mEq/dL, Normal: 3.6 - 5.2 mEq/dL|
|Chloride||115 mEq/dL, Normal: 105- 119 mEq/dL|
|ALT||98 IU/dL, Normal: <75 IU/dL|
|ALP||58 IU/dL, Normal: <100 IU/dL|
|Glucose||140 IU/dL, Normal: 68 - 126 mg/dL|
|Heartworm Test Results||Negative|
|Urinalysis - USG||1.020|
|Urinalysis - Protein||Negative|
|Urinalysis - Biochemical||Negative|
|Urinalysis - Sediment Evaluation||Negative|
|White Blood Cells||12,000/ul|
|Red Blood Cells||41%|
Please reivew the results of Athena's echo.
|Subjective - lesions of valves, myocardium, pericardial space||No valvular degeneration was seen. The left ventricular systolic function is subjectively reduced.|
|LV chamber size and thickness||There is severe left venticular eccentric dilation.|
|Left atrial size||The left atrium is moderately to severely enlarged.|
|LVIDd & LVIDs||Diastole (3.22 cm); Systole (1.41 cm).|
|LV shortening fraction||Left ventricular contractility is significantly reduced with a low fractional shortening of 11%.|
|RA, RV and Pulmonary Artery||Normal.|
|Effusions||No pleural or pericardial effusion.|
|Doppler results||There is moderate mitral valve regurgitation associated with geometric ventricular changes (dilation of the mitral valve annulus). Trivial tricuspid regurgitation.|
Please review Athena's ECG
|Technical quality, leads, paper speed, calibrations||Leads I, II, III, aVR, aVL, 50mm/sec, 10mm/mV|
|Heart Rate||Average = 240/min|
|Rhythm - Regular or irregular | Patterns||Irregularly irregular R-R intervals|
|Heart Rhythm Disturbances||Atrial fibrillation|
|P Wave Abnormalities - morphology, amplitude, duration||Absent P waves|
|QRS Abnormalities - axis, morphology, amplitude, duration||Normal axis with upright QRS complex in Lead II|
|Abnormal Intervals - PR, QRS, QT||QRS is slightly wide (0.06 sec) consistent with left ventricular enlargement|
You're ready to form a diagnosis and treatment plan for Athena! Please select your answer to each question below.
THE CEG RECOMMENDS:
The CEG recommends treatment with a combination of Furosemide, ACEi, Pimobendan(Vetmedin), Digoxin + Diltiazem.
Athena was administered furosemide IV as a 150mg bolus, and 30mg 2 hours later. 15mg of oral pimobendan was administered along with oxygen therapy. After 6 hours, the respiratory rate declined and respiratory effort normalized.
Furosemide - 40 mg tablets
1.5 tablets every 8 hours for 3 days, then decrease to every 12 hours. After the onset of congestive heart failure, furosemide is indicated as a chronic therapy to prevent symptoms of respiratory distress and cough. Twice a day dosing prevents a rebound fluid retention in between doses. High ceiling drug with a dose dependent response.
Enalapril - 10 mg tablets
1.5 tablets every 12 hours. ACE inhibitors are indicated to reduce sodium and water retention, moderate blood pressure and limit the negative remodeling effects of angiotensin II and aldosterone.
Pimobendan - 5mg tablets
3 tablets ever 12 hours. This inodilator has been shown to outperform ACE inhibitors when used with furosemide in prolonging survival in Doberman pinschers with dilated cardiomyopathy and CHF. Pimobendan is indicated at the onset of congestive heart failure and is administered chronically.
Digoxin - 0.125 mg tablets
1 tablet every 12 hours. Digoxin is prescribed to reduce the ventricular response rate to the atrial fibrillation, and to provide mild inotropic support. Dose: 0.003 to 0.004 mg/kg twice daily. Rrough serum digoxin concentration can be measured every 3 months to assure therapeutic drug concentration.
Diltiazem - 30 mg tablets
1 1/2 tablets every 8 hours. This is being used to reduce the ventricular response rate to the atrial fibrillation.
|Diet||Avoid high sodium treats and foods such as processed meats, hot dogs, cheese and some table scraps. Typically commercial dry foods contain half the sodium of commercial canned foods.
|LIST CURRENT MEDICATIONS||TABLET SIZE||LIQUID CONCENTRATE||DOSE|
|Furosemide IV||50 mg/ml||3 ml(150 mg) intial bolus|
|Furosemide IV||50 mg/ml||0.6ml (30 mg)|
|Pimobendan||5 mg||3 tablets|
|ORAL MEDICATIONS TO GO HOME|
|Furosemide||40 mg||1.5 tablets|
|Enalapril||10 mg||1.5 tablets|
|Diltiazem||30 mg||1.5 tablets|