Case Studies

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

Athena

Case Background

Name: Athena
Age: 6 years
Sex: Female
Breed: Doberman
Weight: 30 kg
Reason for Visit: Decreased appetite, cough and labored breathing
Medications: Amoxicillin 500mg: 1 capsule q 12hrs

Clinical History

Please review Athena’s clinical history.

Attitude/Demeanor: Lethargic
Coughing: Coughing for two weeks
Abnormal 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
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 Athena’s physical exam.

Body Condition: Good
Attitude: Quiet
Mobility | Gait: Ambulating normally
Posture: Standing or sternally recumbent
Hydration: Adequate
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: Pale to pink / 3 seconds.
Jugular Venous Pulse & Pressure: No jugular distention
Abdominal Palpatation: Normal
Lymph Nodes: Normal.
Oral Cavity: Normal
Other Abnormalities: None

Physical Exam - Auscultation

Let’s auscult Athena’s heart & lungs.

Listen to Athena’s heart & lungs.
WHAT DO YOU HEAR?
LISTEN TO ATHENA'S THORAX AND LUNGS. DO THEY SOUND NORMAL OR ABNORMAL?

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
DILATED CARDIOMYOPATHY
DEGENERATIVE VALVE DISEASE
PRIMARY RESPIRATORY DISEASE
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.

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 WITH 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: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.

Blood Pressure

Systolic Blood Pressure: 105 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 guidelines for the Identification, Evaluation, and Management of Systemic Hypertension in Dogs and Cats in the 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 Athena’s thoracic radiographs

Click here for Athena’s radiograph viewer (measure VHS and VLAS here) Click here for the right lateral view Click here for the ventral dorsal view Click here to see the CEG’s Practice pointer on evaluating radiographic heart size using VHS and VLAS
WHAT IS THE VERTEBRAL HEART SIZE?
IS ATHENA'S HEART ENLARGED?
IF ATHENA’S HEART IS ENLARGED, WHICH CHAMBERS ARE INVOLVED?
IS THERE EVIDENCE OF CONGESTIVE HEART FAILURE PRESENT (PLEURAL EFFUSION OR PULMONARY EDEMA)?
Technical Quality: Good
Pulmonary Venous Congestion: Yes
Pulmonary Infiltrates: Predominantly perihilar and caudodorsal interstitial

Clinical Labs

Please review Athena’s lab results

SERUM CHEMISTRIES
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/dLHEARTWORM
Heartworm Test Results: NegativeURINALYSIS
Urinalysis – USG: 1.020
Urinalysis – Protein: Negative
Urinalysis – Biochemical: Negative
Urinalysis – Sediment Evaluation: NegativeCBC
White Blood Cells: 12,000/ul
Red Blood Cells: 41%
Platelets: 240,000/ul

Echo

 

Please review 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 (5.6 cm); Systole (5 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.
Watch echo #1

Watch echo #2 Watch echo #3

ECG

Please review Athena’s ECG.

Click to enlarge
RHYTHM DIAGNOSIS IS?
Technical quality, leads, paper speed, calibrations: Leads I, II, III, aVR, aVL, 50mm/sec, 10mm/mV
Artifacts: None
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

Follow Up

7 Day Follow Up: A renal blood panel, an 8-hour post-till serum digoxin concentration, ECG and thoracic radiographs should be performed in 5-7 days . The repeat radiographs are performed to ensure resolution of the pulmonary edema. An ECG is repeated to determine the need for additional rate control medication. The ventricular response rate goal would be an average of 135 bpm on Holter monitor, or less than 160 on an in-house ECG in a calm patient. Thoracic radiographs, ECG, blood pressure and serum biochemistries should be repeated in 3-4 months to check for progression of congestive heart failure and additional rhythm disturbances, if no clinical signs have been noticed earlier.

7 Day Follow Up: Athena was released after diagnostic tests and instituting oral therapy for CHF. She was re-examined 7 days later. The owners have not noticed any coughing or labored breathing since discharge from the hospital. The appetite was reduced for the first 3 days, and is near normal today. Athena ws assessed with a renal panel, 8-hour post-pill serum digoxin concentration, ECG and thoracic radiographs. Renal panel: BUN=37mg/dl; creatinine 1.8mg/dl; phosphorus and electrolytes are within normal limits. Serum digoxin concentration: 0.9ng/dl (sample was drawn 6-8 hours post-pill into a red top tube without a serum separator. Eight-hour post-pill (trough) concentrations between 0.8 and 1.3 ng/dl are ideal to help with rate control and prevent toxicity signs. ECG: Rhythm is still atrial fibrillation, but the rate has been effectively reduced to an average of 150 bpm on the in-house rhythm strip. Thoracic radiographs: Left-sided cardiomegaly with a tall, upright heart consistent with left ventricular enlargement with a moderate to severe caudodorsal bulge consistent with left atrial enlargement. However, the caudodorsal interstitial pattern noted previously is absent on today’s films, and there has been improvement in the pulmonary venous distention. An increase in the furosemide dose is not warranted.

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

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