Case Studies In Small Animal

Cardiovascular Medicine

Home Up 1    Pleural Fluid 2              Cough 3   Heart Murmur 4           Syncope 5       Tachypnea 6           Cyanosis 7   Heart Murmur 8   Heart Murmur 9              Cough 10    Heart Failure 11              Ascites 12    Pleural Fluid 13           Syncope 14     Bradycardia 15     Tachycardia 16                Blind 17   Heart Murmur 18   Resp. Distress 19        Collapsing 20    Heart Failure 21          Paralysis 22    New Murmur 23              Cough 24          Vomiting 25       Tachypnea 26   Heart Murmur 27      Hemoptysis 28  Limb Swelling 29  Heart Murmur 30 Acute Collapse 31 Enlarged Heart 32               Blind 33             Cough 34         Collapse 35         Collapse 36 Thromboembolus 37  Heart Murmur 38  Heart Murmur

.    Radiographs ECG 2D Echo Diagnosis

Case 18

Primary clinician: Aaron Wey, DVM

Supervising clinician: Mark D. Kittleson, DVM, PhD, DipACVIM (Cardiology)

Signalment

bullet10-year-old MC domestic shorthair cat weighing 5 kg ("Grey")

Presenting Complaints

bulletDiabetes mellitus/Fluid in abdomen and chest

Pertinent History

bulletThe client has had Grey since he was a kitten.
bulletApproximately one and a half years ago, he had a four month period of chylothorax, requiring intermittent thoracocentesis.
bulletRestrictive cardiomyopathy was diagnosed 16 months ago and he was started on enalapril 1 tablet (2.5 mg tablet) PO q 24 hours, aspirin 1/4 tablet (80 mg tablet) PO q 3 days, Tumil K 2 tablets PO q 24 hours, and Lasix 1/2 tablet (12.5 mg tablet) PO q 8 hours.
bulletHe had previously been diagnosed with diabetes mellitus, but this resolved in July of 1997.
bulletApproximately six weeks ago, he was diagnosed with diabetes mellitus again; he was started on insulin (owner unsure of type) 4 U SQ BID six days ago, and his Lasix was decreased to 1/2 tablet (12.5mg tablet) PO 1 12 hours.
bulletHe last received insulin this morning.
bulletThe client feels that he has had decreased activity for the last eight weeks, particularly in the last 1-2 weeks.
bulletYesterday, Grey became lethargic and anorexic. He has been vomiting after urination, and appears to have some straining associated with urination.
bulletHe was taken to the referring DVM this evening, where an increased respiratory effort was noted.
bulletThoracic radiographs were taken and showed pleural effusion.
bulletAbdominal effusion (ascites) was also evident.
bulletThe client noted that Grey vomited once after eating, but there has been no coughing, sneezing, or diarrhea.

Physical Examination

bulletOn presentation, Grey is depressed but responsive.
bulletT=93.8, P=120, R=68.
bulletEars are clean.
bulletCornea, conjunctiva, anterior chamber, and sclera are clear.
bulletMucous membranes are pink, with a CRT of 1 seconds.
bulletBreath sounds are audible dorsally and absent ventrally.
bulletHeart is difficult to auscult.
bulletAscites is present, making abdominal palpation difficult.
bulletNo masses or organomegaly detected.
bulletMandibular, prescapular, and popliteal lymph nodes are less than 1/2 cm.

Problems

bulletPleural effusion that is most likely secondary to heart failure
bulletDiabetes mellitus
bulletHypothermia
bulletBradycardia
bulletAscites

Plans and Progress Notes

Problem 1: Pleural effusion

bulletS: Grey was diagnosed with restrictive cardiomyopathy sixteen months ago, after being treated for chylothorax over 3-4 months.
bulletO: On presentation, Grey was dyspneic. A 21-gauge butterfly catheter was used to remove 230 mL of red-colored fluid (200 mL from the left; 30 mL from the right). 
bulletA: Given the prior diagnosis of restrictive cardiomyopathy, it is most likely that this cat is in congestive heart failure.
bulletP: Administer Lasix 20 mg IM. Stabilize cat overnight on 40% oxygen, and continue to monitor respiratory rate and effort. Offer free choice food and water. Tomorrow, submit pleural fluid for analysis and perform echocardiogram to assess cardiac function.

Problem 2: Diabetes mellitus:

bulletS: Grey was diagnosed with diabetes previously, and this resolved in July of 1997. He was diagnosed with diabetes again approximately six weeks ago, and is receiving insulin 4U SQ q 12 hours.
bulletO: Blood glucose at the referring DVM this evening was 240 mg/dL.
bulletA: Diabetes mellitus will need to be addressed once the congestive heart failure has been dealt with. Failure to treat diabetes mellitus for a prolonged period of time can result in diabetic ketoacidosis.
bulletP: Stabilize Grey overnight and assess blood glucose in the morning. Offer free access to w/d.

Problem 3: Hypothermia

bulletO: Grey's temperature is very low.
bulletA: Severe hypothermia that is most likely primarily due to low cardiac output.
bulletP: Treat heart failure and place on a heating pad.

Problem 4: Bradycardia

bulletO: The heart rate is 120 beats/minute.
bulletA: The heart rate is not extremely low and may be mildly decreased because of the hypothermia.
bulletP: Evaluate the ECG

Problem 5: Ascites

bulletO: A brief ultrasound confirmed the presence of ascites and distended hepatic veins.
bulletA: The ascites appears to be due to right heart failure.
bulletP: Treat for heart failure. Perform echocardiogram.

 

Mark D. Kittleson, D.V.M., Ph.D. All rights reserved.