Case Studies

These case studies contain detailed information on the diagnostic and treatment process for each individual animal.

Hailey

Case Background

Name: Hailey
Age: 7 years
Sex: Female, spayed
Breed: Cavalier King Charles Spaniel
Weight: 26.4 pounds (12 kg)
Reason for Visit: Hailey was presented for her yearly physical examination. The family has reported no clinical signs other than bad breath. There has been no cough, respiratory distress, weakness, decreased exercise tolerance or change in appetite
Medications: Heartgard® Plus, no other chronic medications. Last heartworm test was about 2 years prior to this exam.

Clinical History

Please review Hailey’s clinical history.

Attitude/Demeanor: Normal
Coughing: No cough
Abnormal Respirations: None
Exercise intolerance: None
Sleep Patterns: Unchanged
Weight Change (loss or gain): None
Appetite: No change
Usual Diet: Eukanuba™ Adult with some “people food”
Vomiting: None
Diarrhea: None
Syncope: None
Change in urinary habits: None
Change in drinking habits: None
Other symptoms or signs: None

Physical Exam - General

Please review the results of Hailey’s physical examination.

Body Condition: Mildly overweight – BCS 6/9
Attitude: Alert, calm
Mobility | Gait: Normal gait
Posture: Laying in sternal recumbency, resting comfortably
Hydration: Normal
Body Temperature: 100.6 F
Arterial pulse – rate, regularity, intensity: 120 bpm, regularly irregular (with ventilation), normal strength
Rate & Respiratory: Normal effort, 22 breaths per minute
Mucous Membranes – Color & CRT: Pink, <2sec
Jugular Venous Pulse & Pressure: Normal
Abdominal Palpatation: Normal, moderate size bladder
Lymph Nodes: Normal
Oral Cavity: Moderate dental calculus and periodontal inflammation
Other abnormalities: Strong odor from mouth

Physical Exam - Auscultation

Let’s auscult Hailey’s heart
Listen to Hailey’s heart
WHAT DO YOU HEAR?
Direct HR: 100 to 120 beats/min
Heart Rhythm: Suspect respiratory sinus arhythmia
Intensity of Heart Sound: Normal
Extra Sounds – Clicks or Gallops: None
Heart Murmur: Grade 2-3/6 systolic murmur, loudest over the mitral area and left apex. Only soft radiation to the right side.
Precordial Palpation: Normal precordial impulses on the left and right sides.

Physical Exam - Differential Diagnosis

The following are potential diagnosis for you to consider at this time. Based on the history and the physical examination, please indicate the likelihood of each as:
  • High (could explain most or all of the signs)
  • Possible (less likely to explain most of the signs)
  • Unlikely
DEGENERATIVE VALVE DISEASE
PHYSIOLOGIC FLOW MURMUR
CONGENITAL HEART DISEASE
VALVULAR ENDOCARDITIS
The CEG considers the following differential diagnosis as most likely (and why):A cardiac murmur in a patient of this breed and age most likely indicates degenerative (myxomatous) valve disease. The  location and timing of the murmur suggests mitral regurgitation. Physiologic flow murmurs do occur in mature dogs (including the Cavalier King Charles spaniel), but murmurs due to ejection into the aorta or pulmonary artery are typically loudest over the left base (aortic or pulmonary valve areas and into the great vessels).  The presence of a new heart murmur makes congenital heart disease less likely. Although the murmur is “new”, infective endocarditis is unlikely in an otherwise healthy dog. The belief that oral cavity disease commonly leads to endocarditis is not supported by literature studies or clinical experience with echocardiography. (The suspicion would be higher with the clinical findings of fever, polyarthritis, and signs and laboratory findings of constitutional illness and systemic inflammation.) Additionally, the incidence of endocarditis in small breed dogs is low.

Diagnostic Test Selection

BLOOD PRESSURE

NON-INVASIVE BLOOD PRESSURE

CLINICAL LABORATORY

CBC WITH PLATELET COUNT
COAGULATION PROFILE
SERUM BIOCHEMICAL PROFILE (INCLUDES ELECTROLYTES)
URINALYSIS
SERUM THYROXINE (T4)
HEARTWORM ANTIGEN TEST
HEARTWORM ANTIBODY TEST
HEARTWORM MICROFILARIA TEST
NT-PROBNP
CARDIAC TROPONIN-I
BLOOD CULTURE
THORACOCENTESIS OR ABDOMINOCENTESIS FOR DIAGNOSIS OR THERAPY

DIAGNOSTIC IMAGING (some may require a referral)

THORACIC RADIOGRAPHS
ABDOMINAL RADIOGRAPHS
ECHOCARDIOGRAM DOPPLER STUDIES
ABDOMINAL ULTRASOUND

ELECTRODIAGNOSTICS (some may require a referral)

ECG RHYTHM STRIP OR 6 LEAD ECG
AMBULATORY ECG - HOLTER ECG OR EVENT MONITOR
The CEG considers the following diagnostic tests as the highest priority:A new cardiac murmur in a patient of this breed and age is likely to be caused by degenerative (myxomatous) valve disease. The lack of symptoms suggests an ACVIM stage B patient (i.e., evidence of structural heat disease without clinical signs of heart failure). However, further staging of the disease requires imaging of the heart. This can be accomplished by thoracic radiography or echocardiography, which along with a blood pressure measurement, are the CEG’s highest priorities. Additional cardiac studies including an ECG (to verify the rhythm) and NT-pBNP (to reasonable

Blood Pressure

Systolic Blood Pressure: 135 mmHg
Diastolic Blood Pressure: Not available for this case
Mean Blood Pressure: Not available for this case
Consensus Statements of the American College of Veterinary Internal Medicine (ACVIM) provides the veterinary community with up-to-date information on the pathophysiology, diagnosis, and treatment of clinically important animal diseases. In 2018, ACVIM published updated guidelines for the Identification, Evaluation, and Management of Systemic Hypertension in Dogs and Cats in the Journal of Veterinary Internal Medicine. Click here to view and download a PDF of the ACVIM Consensus Statement, Guidelines for the Identification, Evaluation, and Management of Systemic Hypertension in Dogs and Cats.

Radiographs

Please review Hailey’s thoracic radiographs.
Click here for ventral dorsal view Click here for right lateral view
WHAT IS THE VERTEBRAL HEART SIZE (VHS)?
IS HAILEY'S HEART SIGNIFICANTLY ENLARGED?
IS PULMONARY EDEMA PRESENT?
Technical Quality: Good
Pulmonary Venous Congestion: Normal pulmonary vasculature, no congestion noted.
Pulmonary Infiltrated Distribution: None.
Pulmonary Infiltrate Pattern: Mild bronchointerstitial pattern.
Other Findings: n/a

Clinical Labs

SERUM CHEMISTRIES

BUN: 19 mg/dL, Normal: <30 mg/dL
Creatinine: 1.1 mg/dL, Normal: <2.1 mg/dL
Sodium: 144 mEq/L, Normal:138 – 154 mEq/L
Potassium: 4.4 mEq/L, Normal: 3.6 – 5.2 mEq/L
Chloride: 113 mEq/L, Normal: 105 – 119 mEq/L
ALT: 40 IU/L, Normal: <75 IU/L
ALP: 56 IU/L, Normal: <100 IU/L

HEARTWORM

Heartworm: Test Results Negative

URINALYSIS

Urinalysis – USG: 1.024
Urinalysis – Protein: Negative
Urinalysis – Biochemical: Normal
Urinalysis – Sediment Evaluation: Norm

Echocardiography

Please review the results of Hailey’s echo

Subjective – lesions of valves, myocardium, pericardial space: No pericardial effusion; normal systolic function of the left ventricle, thickened mitral leaflets with posterior leaflet mitral valve prolapse.
LV chamber size and thickness: Normal thickness but high normal to mildly increased chamber diameter.
Left atrial size: Mild dilation
LVIDd & LVIDs: Diastole (3.4 cm); systole (2.2 cm).
LV shortening fraction: Normal – 35%
RA, RV and Pulmonary Artery: Not remarkable (detailed images not shown).
Effusions: None.
Doppler results: Mitral regurgitation (MR); eccentric jet of MR is typical of primary valve disease; velocity of MR predicts normal systemic pressures; No tricuspid valve regurgitation (TR). Normal mitral inflow velocities.

ECG

Click here to view ECG results

Technical Quality, Leads, Paper Speed, Calibrations: Satisfactory recording; 6 frontal leads and lead 2 rhythm strip recorded; paper speed 50 mm/sec; calibration 10mm/mV.
Artifacts: No significant
Rhythm- regular or irregular/ patterns: Regularly irregular. Heart rate 110 bpm.
Heart Rhythm Disturbances: Respiratory sinus arrhythmia; no premature complexes were detected.
P Wave Abnormalities- morphology, amplitude, duration: Normal P wave height and width.
QRS Abnormalities- axis, morphology, amplitude, duration: Normal frontal axis, no significant increase in height or width (insensitive measurement of chamber size).
Abnormal Intervals- PR, QRS, QT: Normal intervals.
Other: Slurred ST segments.

    The CEG is funded through an educational grant from Boehringer Ingelheim Vetmedica, Inc., IDEXX Laboratories, Inc. and Nestle Purina PetCare.

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