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Whispurr's specialist reports

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  • Jim Sinclair
    SUMMARY OF APRIL 10 CARDIOLOGY CONSULT PROBLEM(S)/DIAGNOSIS COMMENTS Unclassified cardiomyopathy Severe biatrial enlargement, biventricular systolic
    Message 1 of 3 , May 16, 2014
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      SUMMARY OF APRIL 10 CARDIOLOGY CONSULT

      PROBLEM(S)/DIAGNOSIS COMMENTS
      Unclassified cardiomyopathy Severe biatrial enlargement, biventricular
      systolic dysfunction
      Spontaneous echo contrast within the left atrium
      Mild mitral and tricuspid regurgitation
      Abdominal effusion Proteinaceous (4.6gm/dl on 3/21/14)

      HISTORY: Whispurr was referred for further evaluation of abdominal
      effusion and a new heart murmur. Whispurr has had chronic upper
      respiratory disease throughout her life, which includes ocular
      discharge and sneezing, for which she is treated intermittently with
      antibiotic therapy (azithromycin and doxycycline). Over the last 3
      years she has had
      chronic diarrhea and intermittent vomiting [note: she has NOT had
      chronic diarrhea, she has had intermittent gastritis with vomiting
      and/or diarrhea, with normal stools between episodes], as well as
      episodes of hyporexia and lethargy. She has always fluctuated in
      weight. Blood work done in January 2014 revealed a mild increase in
      AST (108), severe increase in CK (2372); mild hypoproteinemia (5.5)
      and hypoglobulinemia (2.8), mild increase in BUN (39), mild decrease
      in creatinine (0.5), mild hypocalcemia (8.5) and hypophosphatemia
      (2.7); moderate non-regenerative anemia (22.5%) and mild monocytosis
      (571); mild decrease in T4 (0.6); moderately low cobalamin (<150) and
      folate (3.1); and significantly increased NTproBNP >1500 pmol/L.
      Radiographs were also done at this time, revealing a severely
      distended stomach with foreign material, perotineal effusion and
      cardiomegaly. She was placed on a vitamin B12 and vitamin B complex
      injections at that time. Her appetite has improved, however her
      abdomen became progressively distended. On 3/19/14, she presented for
      the abdominal distension and an abbreviated chemistry panel was
      performed and was unremarkable. A diagnostic abdominocentesis was
      performed on 3/21, revealing a fluid total protein of 4.6 gm/dl. At
      that time she was started on lasix 6.25mg PO q24h. A therapeutic
      abdominocentesis was performed on 3/28/14, yielding 75ml of fluid.
      Since that time, the owner has noted a mild increased abdominal effort
      to her breathing, with no increase in resting RR or exercise
      intolerance. Whispurr was also diagnosed with melting corneal ulcer in
      February, which is currently being treated with Remend corneal repair
      gel OD BID. The owner is also giving CoQ10 50mg SID and Nattokinase
      (anticoagulant) 2000fu SID.

      PHYSICAL EXAMINATION: Temp: 100.0 F; Pulse: 220 bpm; Resp: 60/min; Wt:
      6.5 lbs (2.95 kg); BCS: 3/9

      Whispurr is bright, alert and responsive. Hydration appears adequate.
      Pink, moist mucous membranes, CRT < 2 seconds. Thoracic auscultation
      reveals a prominent gallop sound, no murmurs or arrhythmias, and clear
      lung sounds. Femoral pulses are fair and synchronous. Abdominal
      palpation soft and doughy. Peripheral lymph nodes are normal.

      DIAGNOSTICS: Doppler systolic 1. blood pressure:
      • Patient Position: Right lateral
      • Limb used: Left forelimb
      • Cuff size: 2 cm
      • Systolic BP (mmHg): 94-100 (normal 90-150 mmHg)

      2. Thoracic Radiographs:
      • Vertebral heart score (VHS): 9.2 (normal dog < 10.7)
      • Interpretation: Moderate cardiomegaly with biatrial enlargement.
      Pulmonary vessels are prominent. Mild bronchointerstitial pattern is
      present dorsal and ventral to the caudal vena cava.

      3. See attached.
      4. CBC/Chem: pending
      5. FIP PCR (abdominal fluid): pending

      MEDICATION:
      Furosemide (Lasix), 12.5 mg tablets Diuretic Give 1/4 (1mg/kg) tablet
      by mouth twice daily (DECREASE)

      Benazepril, 5 mg tablets (NEW) ACE Inhibitor Give 1/4 tablet
      (0.4mg/kg) by mouth once daily

      Pimobendan (Vetmedin), 1.25 mg tablets (NEW) Inodilator Give 1/2
      tablet (0.21mg/kg) by mouth twice daily

      Clopidogrel (Plavix), 75 mg tablets (NEW) Anti-platelet Give 1/4
      tablet by mouth once daily

      CoQ10, Nattokinase Supplements DISCONTINUE

      FEEDING: As usual EXERCISE: Allow Whispurr to set her own pace

      A RECHECK IS RECOMMENDED: In 1-2 weeks for recheck Doppler blood
      pressure, renal panel with electrolytes

      ADDITIONAL COMMENTS AND INSTRUCTIONS: Whispurr has been diagnosed with
      unclassified cardiomyopathy, which is a general classification for
      cats with heart disease that does not fit into the major categories of
      heart disease (hypertrophic, dilated or restrictive cardiomyopathies).
      The contractitilty of her heart muscle is weak, and her atria (top
      chambers of her heart) are severely dilated. To help slow progression
      of her heart disease, and treat her for possible congestive heart
      failure, we are starting her on several medications. Lasix, which she
      is currently taking, is a diuretic that helps to rid the body of
      excess fluid. Benazepril helps to prevent fluid retention, as well as
      control certain hormones that are elevated with significant heart
      disease. Pimobendan helps to improve contractility of the heart, and
      improve the ability of the heart to pump blood out to the
      body. And clopidogrel (Plavix), is an antiplatelet medication used to
      prevent blood clot formation within Whispurr's enlarged atria.

      At this time, although Whispurr's heart disease is severe enough to
      cause congestive heart failure (fluid build-up), the high protein
      level of the fluid in her abdomen makes me concerned that it may not
      be related to her heart disease. We have submitted the fluid for a PCR
      test for FIP, and will call you as soon as results are available. In
      the
      meantime, we will treat her for heart failure (see above). [The PCR
      test came back negative.]

      Please watch Whispurr for development of symptoms such as: loss of
      appetite, vomiting, diarrhea, weakness, decreased activity level or
      collapse, increased respiratory rate (normal respiratory rate is less
      than 30 breaths per minute, call if greater than 35, or greater than
      20% increase), difficulty breathing, abdominal distention, sudden
      onset of lameness or blindness. If you notice any of these, or if you
      have any questions or concerns, please contact myself or your regular
      veterinarian to discuss an appropriate plan.

      APRIL 10 BLOOD WORK

      ALP 20 12 - 59 U/L
      ALT 79 27 - 158 U/L
      AST 59 16 - 67 U/L
      CREATINE KINASE 523 64 - 440 U/L HIGH
      GGT 0 0 - 6 U/L
      AMYLASE 1022 623 - 2239 U/L
      LIPASE 119 11 - 242 U/L
      ALBUMIN 3.3 2.6 - 3.9 g/dL
      TOTAL PROTEIN 6.5 6.3 - 8.8 g/dL
      GLOBULIN 3.2 3.0 - 5.9 g/dL
      TOTAL BILIRUBIN 0.1 0.0 - 0.3 mg/dL
      BILIRUBIN -
      CONJUGATED 0.0 0.0 - 0.2 mg/dL
      BUN 34 16 - 37 mg/dL
      CREATININE 0.8 0.9 - 2.5 mg/dL LOW
      CHOLESTEROL 127 91 - 305 mg/dL
      GLUCOSE 111 72 - 175 mg/dL
      CALCIUM 10.0 8.6 - 10.6 mg/dL
      PHOSPHORUS 5.0 2.9 - 6.3 mg/dL
      TCO2
      (BICARBONATE) 17 12 - 22 mmol/L
      CHLORIDE 116 114 - 126 mmol/L
      POTASSIUM 5.0 3.7 - 5.2 mmol/L
      SODIUM 151 147 - 157 mmol/L
      ALB/GLOB RATIO 1.0 0.5 - 1.2
      BUN/CREATININE
      RATIO 42.5
      BILIRUBIN -
      UNCONJUGATED 0.1 0.0 - 0.2 mg/dL
      NA/K RATIO 30 29 - 42
      HEMOLYSIS INDEX N 1
      LIPEMIA INDEX N 2
      ANION GAP 23 12 - 25 mmol/L

      Comments:
      1. Index of N,+,++ exhibits no significant effect on chemistry values.
      2. Index of N,+,++ exhibits no significant effect on chemistry values.
      TOTAL HEALTH : CBC COMPREHENSIVE
      Test Result Reference Range Low Normal High
      WBC 11.9 3.9 - 19.0 K/uL
      RBC 7.73 7.12 - 11.46 M/uL
      HGB 10.1 10.3 - 16.2 g/dL LOW
      HCT 33.5 28.2 - 52.7 %
      MCV 43 39 - 56 fL
      MCH 13.1 12.6 - 16.5 pg
      MCHC 30.1 28.5 - 37.8 g/dL
      % RETICULOCYTE 0.5 %
      RETICULOCYTE 39 3.0 - 50.0 K/uL
      % NEUTROPHIL 73.8 %
      % LYMPHOCYTE 15.5 %
      % MONOCYTE 3.2 %
      % EOSINOPHIL 7.5 %
      % BASOPHIL 0.0 %
      AUTO PLATELET 369 155 - 641 K/uL
      REMARKS SLIDE REVIEWED MICROSCOPICALLY.
      NEUTROPHIL 8782 2620 - 15170 /uL
      LYMPHOCYTE 1845 850 - 5850 /uL
      MONOCYTE 381 40 - 530 /uL
      EOSINOPHIL 893 90 - 2180 /uL
      BASOPHIL 0 0 - 100 /uL

      APRIL 10 ECHOCARDIOGRAM

      PE: Prominent gallop sound. No murmurs or arrhythmias identified.
      Clear lung sounds. Femoral pulses fair and synchronous.

      ECG during echo: Sinus tachycardia

      2D
      Ao Diam 0.85 cm
      LA Diam 1.88 cm
      LA/Ao 2.21
      IVSd 0.58 cm
      LVIVd 1.52 cm
      LVPWd 0.52 cm
      IVSs 0.65 cm
      LVIDs 1.19 cm
      %FS 21.72%
      LVPWs 0.63 cm

      M-Mode
      Ao Diam 0.79 cm
      LA Diam 1.94 cm
      LA/Ao 2.46

      Doppler
      MV E Vel 0.79 m/s
      MV Eann Vel 0.07 m/s
      MV E/Eann Ratio 10.95
      AV Vmax 0.89 m/s
      AV maxPG 3.20 mmHG
      PV Vmax 0.65 m/s
      PV maxPG 1.67mmHG
      TR Vmax 2.03 m/s
      TR maxPG 16.48mmHG


      Echocardiogram Findings

      2D/M-mode:
      The left ventricular internal dimensions are within normal limits in
      end-diastole, but increased in end-systole.
      There is systolic dysfunction.
      The left atrium is severely enlarged.
      There is spontaneous echo contrast.
      No systolic anterior motion of the mitral valve.
      The left ventricular outflow tract and aortal valve appear normal.
      The right ventricle appears subjectively normal in size; there is
      subjective right ventricular systolic dysfunction.
      The right atrium is severely enlarged.
      The tricuspid valve leaflets appear normal.
      The right ventricular outflow tract and pulmonic valve appear normal.
      No masses noted.
      No pleural/pericardial effusion.

      Color/Spectral Doppler:
      There is mild mitral regurgitation.
      There is mild, low velocity tricuspid regurgitation.
      No aortic or pumonic insufficiency.
      Transmitral flow velocities and tissue Doppler are fused.
      There is laminar flow in both ventricular outflow tracts, with normal
      transaortic and transpulmonic velocities.

      Diagnosis:
      1. Unclassified cardiomyopathy - severe liatrial enlargement with
      biventricular systolic dysfunction
      2. Spontaneous echo contrast in left atrium
      3. Mild mitral and tricuspid regurgitation




      At the time of this April 10 consult, the cardiologist prescribed a
      decreased dose of furosemide, 1/4 table (12.5 mg tablets) twice a day
      instead of 1/2 tablet twice a day. She added new prescriptions for
      benazepril, 5 mg tablets, 1/4 tablet daily; pimobendan suspension from
      a compounding pharmacy, 2.5 mg/ml suspension, 0.25 ml daily; and
      clopidogrel (Plavix), 75 mg tablets, 1/4 tablet daily. She recommended
      discontinuing the CoQ10 and the nattokinase. I did discontinue the
      nattokinase based on the cardiologist's concern that giving two
      "anticoagulants" (the nattokinase and the clopidogrel) together might
      be dangerous, but I have continued the CoQ10 because the cardiologist
      said it would not do any harm, she just doesn't think it's necessary.

      By April 15 I was noticing a growing belly and hard-belly breathing. I
      took her for a recheck. Her weight had increased from 6.5 to 6.94
      pounds. Temp 97.5 F, pulse 186, resp 80 (purring). She was given an
      injection of Lasix 6 mg and I was instructed to return her furosemide
      dose to 1/2 tablet twice a day.

      On April 29 she had a recheck. Temp 100.2, pulse 160, resp 66, weight
      5.75. Doppler systolic blood pressure was 88-92. Renal panel showed no
      significant abnormalities. Cardiologist was pleased.

      This week I began noticing her belly looking a bit larger again and
      her breathing seeming faster. I left a message for the cardiologist,
      in the midst of a crisis involving another of my cats who went back
      and forth between the ER and primary vet and died Wednesday afternoon.
      At the time I went to pick up her body for necropsy (at the same
      hospital where Whispurr was evaluated), the ER vet gave me a note from
      the cardiologist instructing me to increase Whispurr's furosemide dose
      and add a new prescription for spironolactone, and get more blood work
      done in a couple weeks. We started the new med regimen Wednesday
      night. I don't know yet if it's making any difference.

      Whispurr's current meds are:

      Furosemide 12.5 mg tablets, 1/2 tablet in the morning and 1 full tablet at night
      Benazepril 5 mg tablets, 1/4 tablet at night
      Clopidogrel 75 mg tablets, 1/4 tablet at night
      Pimobendan 2.5 mg/ml suspension, 0.25 ml twice a day
      Spironolactone 25 mg tablets, 1/4 tablet at night

      In the mornings I give her the half-tablet of furosemide and the
      squirt of pimobendan, and I add the CoQ10 powder to her breakfast. At
      night I put the full tablet of furosemide and the quarter-tablets of
      benazepril, clopidogrel, and spironolactone into an empty capsule and
      give them together, along with another squirt of pimobendan.

      Jim Sinclair jisincla@...
    • Jim Sinclair
      ... at night ... It s been almost two weeks since increasing the Lasix and adding the spironolactone. Whispurr has an appointment tomorrow for a recheck and a
      Message 2 of 3 , May 27, 2014
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        On May 16, 2014 2:37 PM, I wrote:

        > Whispurr's current meds are:
        >
        > Furosemide 12.5 mg tablets, 1/2 tablet in the morning and 1 full tablet at night
        > Benazepril 5 mg tablets, 1/4 tablet at night
        > Clopidogrel 75 mg tablets, 1/4 tablet at night
        > Pimobendan 2.5 mg/ml suspension, 0.25 ml twice a day
        > Spironolactone 25 mg tablets, 1/4 tablet at night
        >
        > In the mornings I give her the half-tablet of furosemide and the
        > squirt of pimobendan, and I add the CoQ10 powder to her breakfast. At
        > night I put the full tablet of furosemide and the quarter-tablets of
        > benazepril, clopidogrel, and spironolactone into an empty capsule and
        > give them together, along with another squirt of pimobendan.

        It's been almost two weeks since increasing the Lasix and adding the spironolactone. Whispurr has an appointment tomorrow for a recheck and a renal panel. She is still acting fine, eating well, getting around without apparent difficulty, purring, but her belly still looks distended. Also, she is having soft mushy stools that smell really bad. As I think I described in an earlier post, in January she had X rays which showed lots of gas and some unidentified foreign material in her GI tract (fortunately not obstructing), and for a while we were more concerned about her gut than her heart. Her cobalamin and folate were low and she has been getting weekly injections of B12 plus B complex since January. What questions should I ask the cardiologist to figure out whether the distended belly is from fluid due to CHF or gas due to GI disease? Whether the soft stinky stools are from GI disease or side effects of any of the five medications she's on? Any other questions I should ask?

        Jim Sinclair  jisincla@...

      • Anita Hamer
        My boy is on most of the same meds. He takes Toursamide rather than furosemide, doesn t take Benazepril and his Pimobendan is 1.25 mg. We.ve never experienced
        Message 3 of 3 , May 27, 2014
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          My boy is on most of the same meds. He takes Toursamide rather than furosemide, doesn't take Benazepril and his Pimobendan is 1.25 mg. We.ve never experienced bowel issues. So I would say that the heart meds are not the cause of the pungent loose stools.
           
          Have you made any dietary changes lately? If so that can cause gastric disturbance,
           
          Anita and Squeaker


          On Tuesday, May 27, 2014 11:33 PM, "Jim Sinclair jisincla@... [feline-heart]" <feline-heart@yahoogroups.com> wrote:


           
          On May 16, 2014 2:37 PM, I wrote:
          > Whispurr's current meds are:
          >
          > Furosemide 12.5 mg tablets, 1/2 tablet in the morning and 1 full tablet at night
          > Benazepril 5 mg tablets, 1/4 tablet at night
          > Clopidogrel 75 mg tablets, 1/4 tablet at night
          > Pimobendan 2.5 mg/ml suspension, 0.25 ml twice a day
          > Spironolactone 25 mg tablets, 1/4 tablet at night
          >
          > In the mornings I give her the half-tablet of furosemide and the
          > squirt of pimobendan, and I add the CoQ10 powder to her breakfast. At
          > night I put the full tablet of furosemide and the quarter-tablets of
          > benazepril, clopidogrel, and spironolactone into an empty capsule and
          > give them together, along with another squirt of pimobendan.
          It's been almost two weeks since increasing the Lasix and adding the spironolactone. Whispurr has an appointment tomorrow for a recheck and a renal panel. She is still acting fine, eating well, getting around without apparent difficulty, purring, but her belly still looks distended. Also, she is having soft mushy stools that smell really bad. As I think I described in an earlier post, in January she had X rays which showed lots of gas and some unidentified foreign material in her GI tract (fortunately not obstructing), and for a while we were more concerned about her gut than her heart. Her cobalamin and folate were low and she has been getting weekly injections of B12 plus B complex since January. What questions should I ask the cardiologist to figure out whether the distended belly is from fluid due to CHF or gas due to GI disease? Whether the soft stinky stools are from GI disease or side effects of any of the five medications she's on? Any other questions I should ask?
          Jim Sinclair  jisincla@...


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