|Weight||9.4 kg (20.68 lbs)|
|Reason for Visit||Cough: dog was treated for kennel cough about 6 months ago. Helped for a "little while" then the cough came back. Multiple antibiotic trials produced minor improvement. Prednisone trial resolved cough but cough returned after prednisone was discontinued.|
|Medications||Amoxicillin 500mg: 1 capsule q 12hrs|
|Heartworm Prevention||Receiving monthly preventative 12/12 months.|
|Doxycycline 1st||Cough improved but not gone, dog vomited on doxycycline.|
|Amoxicillin-clavulanic acid||No change in cough, discussed further workup, decided on prednisone trial and referral if no response.|
|Prednisone, tapering dose (next after amoxicillin-clavulanic acid)||Cough resolved on prednisone therapy then returned after prednisone was discontinued. Patient was referred for further evaluation.|
Please review Hershey's clinical history.
|Coughing||Leash elicits cough, coughs in middle of night and with excitement. Non-productive honking cough|
|Sleep Patterns||Sometimes coughs in the middle of the night|
|Weight Change (loss or gain)||Gained weight when receiving prednisone|
|Appetite||Increased appetite when receiving prednisone|
|Usual Diet||Purina One® with some table scraps and cold cut treats|
|Vomiting||None since stopping doxycycline|
|Change in Urinary Habits||None|
|Change in Drinking Habits||Increased urination when receiving prednisone|
|Other Symptoms or Signs||Increased water intake when receiving prednisone|
Please review the results of Hershey's physical exam.
|General Body Condition||Normal|
|Mobility | Gait||Normal|
|Body Temperature||101.6 F|
|Arterial Pulse - rate, regularity, intensity||120 bpm, regular, normal strength|
|Respiratory Rate & Effort||30, Normal|
|Mucous Membranes - Color & CRT||Pink < 2 sec|
|Jugular Venous Pulse & Pressure||Non-distended|
|Abdominal Palpatation||No abnormalities, soft, non painful|
|Oral Cavity||Mild dental tartar is present without evidence of periodontal disease|
Let's auscult Hershey's heart & lungs.
Direct HR: 120 bpm
Heart Rhythm: Rhythm is regular
Intensity of Heart Sounds: Normal
Extra sounds - clicks or gallops: None
Precordial Palpation: No abnormalities
The CEG considers the following differential diagnosis as most likely (and why):
The presence of the clinical sign of cough without abnormal cardiac auscultatory findings make a respiratory cause of the cough more likely in this patient. However some cardiac diseases, like dilated cardiomyopathy, may not have a heart murmur on auscultation, so cannot be completely ruled out in this case. The history of a positive clinical response to steroids also supports a respiratory etiology for the cough; most patients that have a cough due to cardiomegaly will not improve with steroid therapy. Possible common respiratory conditions that could be associated with a cough in older small breed dogs include tracheal collapse, pneumonia, airway inflammation (bronchitis, either infectious or inflammatory) and pulmonary neoplasia. Other less common causes of cough may include problems like airway foreign body, laryngeal dysfunction or hilar lymphadenopathy.
The CEG considers the following diagnostic tests as the highest priority:
Since the history and physical exam findings make respiratory disease more likely as a cause of cough than cardiac disease, the CEG considers thoracic radiographs to be the highest priority test in this patient. Thoracic radiographs will provide the best opportunity to examine the airways and pulmonary parenchyma for evidence of disease. In addition, the appearance of the pulmonary vasculature can be scrutinized for findings compatible with pulmonary hypertension (e.g. main pulmonary artery enlargement, enlarged and/or tortuous peripheral pulmonary arteries). Lastly, the cardiac silhouette can be examined for evidence of chamber enlargement that might indicate development of pulmonary hypertension (i.e. right-sided chamber enlargement) or evidence of "silent" heart disease (e.g. dilated cardiomyopathy, with evidence of left-sided or four chamber enlargement patterns).
Echocardiography may be viewed as a lower priority test, to be recommended if the thoracic radiographic results do not suggest a diagnosis or present confusing or conflicting results. Doppler-echocardiography can be used to screen for pulmonary hypertension and to provide evidence of anatomic or functional abnormalities that may be contributing to clinical signs.
A laboratory evaluation consisting of a CBC, chemistry and urinalysis may be recommended as a screening tool for pneumonia (CBC) or metabolic abnormalities (chemistry/urinalysis) that may be complicating the clinical picture or may occur as a result of previous therapies in an older patient. This patient has had a relatively reliable heartworm preventative administration history, but a repeat heartworm antigen test may be indicated if the last test was > 1 year ago, or if the thoracic radiographs reveal findings compatible with heartworm disease (i.e. enlarged pulmonary vasculature, right-sided heart enlargement alveolar infiltrates).
The CEG did not consider additional testing necessary at this time, but specific tests may be chosen if the first tests do not suggest diagnosis, or uncover additional abnormalities that require investigation.
Please review Hershey's thoracic radiographs
Please review Hershey's lab results
|BUN||27 mg/dL Normal: <30 mg/dL|
|Creatinine||0.7 mg/dL Normal: 0.6 - 2.1 mg/dL|
|Sodium||151 mm0l/L Normal:138 - 154 mm0l/L|
|Potassium||5.0 mm0l/L Normal: 3.6 - 5.2 mm0l/L|
|Chloride||110 mm0l/L Normal: 105- 119 mm0l/L|
|ALT||72 IU/L Normal: <75 IU/L|
|ALP||96 IU/L Normal: <100 IU/L|
|Heartworm Test Results||Negative Antigen Test|
|Urinalysis - USG||1.025|
|Urinalysis - Protein||Negative|
|Urinalysis - Biochemical||Not Done|
|Urinalysis - Sediment Evaluation||Quiet Sediment|
|White Blood Cells||Total Count 9.92 x10^3/ul, normal differential|
|Red Blood Cells||45%, TP: 7.4 g/dl|
|Platelets||421 x 10^3/ul|
You're ready to form a diagnosis and treatment plan for Hershey! Please select your answer to each question below.
More Information: Fluoroscopy was recommended to rule out dynamic airway collapse as a cause of cough. The fluoroscopic study showed significant intrathoracic airway collapse during coughing. Dynamic tracheal collapse was diagnosed. Bronchoscopy can also be performed to diagnose airway collapse. Bronchoscopic examination can be combined with an airway wash for cytologic examination and culture.
0.25-0.5 mg/kg PO once daily, if possible taper to lowest effective dose every other day for chronic therapy.
Corticosteroids are effective to decrease the chronic inflammation that may cause "dry" cough in dogs with chronic bronchitis. Tapering the dose to the lowest effective dose helps to limit unwanted side effects of chronic corticosteroid administration.
1.25-2.5 mg PO up to 3 times per day as needed to lessen cough
Hydrocodone was used as cough suppressant in this patient. Oral butorphanol can be used instead of hydrocodone if desired. Cough suppressants can be helpful for "night-time" coughers because of their mildly sedative side effects (vary with dose). The dose of cough suppressant should be decreased if the patient is excessively sedated.
|Lifestyle Adjustments||Limit activity on hot/humid days if coughing is provoked. Use a harness rather than a collar for leash walks.|