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 39 Ascites

Radiographs ECG 2D Echoes Color Flow Doppler Angiogram Diagnosis

Case 39

Primary Clinician: Anna Paling, DVM

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

Signalment

bulletFive-year-old female spayed Labrador Retriever ("Sarah")

Presenting Complaint

bulletAscites

Pertinent History

bulletSarah was presented to the UC Davis VMTH Cardiology Service for further evaluation and possible treatment of congenital heart disease. Her owner had been in a car accident last summer and his sister took over Sarah's care shortly thereafter. She reports that Sarah would exercise normally and had a normal activity level at that time. After her OVH 3 months ago, Sarah's owner noticed that she began coughing and had some abdominal distension. The abdominal distension has gotten progressively worse since that time. She has also had a progressive reduction in activity level and appetite, and is now exercise intolerant. About twice a month, Sarah has collapsing episodes during which time she seems dazed and confused for about 5 seconds; these are usually brought on by exercise or excitement. The owner has noted collapsing episodes for 6 months but did not know the etiology. The owner has also noticed that Sarah has been having respiratory difficulty for the past month. A heart murmur has not previously been diagnosed.
bulletPERTINENT HISTORY:
bulletNo pertinent medical history prior to new ownership starting 6 months ago.
bullet6 months ago: Presented to first veterinary clinic for walking strangely and possible collapse with activity. No diagnostic workup at that time.
bullet4 months ago: Presented because she had two episodes where she fell on her side and staggered. CBC/blood chemistry panel was normal. Ddx - possible epilepsy.
bullet3 months ago: OVH
bullet3 months ago: Presented to check incision (bruising) and for cough/gag. Owner to monitor.
bullet3 months ago: Recheck - still coughing. Rx: Amoxicillin 750mg BID x 14 days. Possible abdominal distention which was not worked up further.
bullet1 month ago: Presented to a different veterinary clinic for abdominal distension. Pale mm with prolonged CRT. Low output signs. Ddx: congestive heart failure
bullet4 weeks ago: CBC/ chemistry panel  - normal
bullet3 weeks ago: Abdominal ultrasound revealed a large amount of abdominal fluid, moderate hepatomegaly with mottled texture, severe hepatic vein and caudal vena caval distension. Brief cardiac exam revealed severe right atrial enlargement. Recommended evaluation by cardiology specialist.
bullet3 weeks ago: Furosemide 80mg BID started by referring DVM. Abdominocentesis attempted but not accomplished.
bullet2 weeks ago: Furosemide increased to 80mg TID due to progressive abdominal distention. Benazepril 15mg daily started.
bulletCURRENT MEDICATION:
bulletFurosemide 80mg q8 hours
bulletBenazepril 15 mg q24 hours
bulletSarah has not had a successful abdominocentesis performed.

Physical Examination

bulletGEN: QAR, 5-8% dehydrated based on decreased skin turgor and pale, tacky mm; very weak and lethargic. P=140-150 R=32. Ambulatory x 4 with assistance. Cold extremities.
bulletINT: Smooth, full hair coat. Salivary staining interdigitally of all paws. 5cmx2cm area of alopecia with raised, thickened dermis over right metatarsals (presumed acral lick granuloma). No evidence of ectoparasites seen.
bulletEENT: Symmetric face with no muscle atrophy. Clear conjunctiva, anterior chambers, corneas, and scleras OU. PLRs intact, direct and consensual. No ocular discharge noted. Moderate ceruminous debris and erythema AU. Clean dry nose. Pale, tacky mucous membranes. Clean teeth with no dental calculus or plaque. No oral masses or foreign bodies seen.
bulletMS: BCS 6/9. No lameness noted; strong symmetric gait.
bulletCV: Muffled heart sounds; difficult to auscult, particularly over right hemithorax. Soft diastolic murmur possibly ausculted over left hemithorax. No systolic murmur ausculted. Extra heart sound ausculted during early diastole. Pulses weak and symmetric. CRT 2.5 seconds. No obvious jugular pulsation, but subcutaneous edema of the neck noted.
bulletRESP: Mildly tachypneic, no crackles, wheezes, or stridor ausculted. Referred upper airway noises. Short, shallow breathing pattern.
bulletGI: Abdomen soft and distended, with fluid wave palpable. Non-painful. Hepatomegaly palpated.
bulletLN: Mandibular, prescapular, and popliteal lymph nodes less than 1 cm.

Problems

bulletAscites most likely due to right heart failure
bulletClinical signs suggestive of low cardiac output
bulletAbnormal heart sounds
bulletDehydration

Medical/Surgical Procedure

bulletAbdominocentesis: 4.25 L serosanguinous fluid removed on presentation to Cardiology Service. Fluid was consistent with a modified transudate.

 

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