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Case 5
Follow-Up
Clinical Diagnoses
 | Severe hypertrophic cardiomyopathy (HCM) with left heart failure (pulmonary edema) |
| Systolic anterior motion (SAM) of the mitral valve secondary to the HCM - seen on
the two-dimensional echocardiogram and color flow Doppler pictures on the previous page. |
Plans and Progress Notes
| 6/11/98 11:00 AM S/O: Thoracic radiographs revealed an enlarged cardiac
silhouette with marked ventral alveolar and interstitial pulmonary infiltrates. The
pulmonary arteries are enlarged. Lasix 8 mg (2mg/kg) was given IV at 9:15 AM and repeated
IM at 10:30 AM. She was placed in an oxygen cage at 9AM at 40-50% O2. She urinated at
10AM. Her respiratory rate at 10 AM had decreased to 80 breaths/minute. Cardiology consult confirmed
hypertrophic cardiomyopathy via ultrasound. She was placed on 1/4 inch nitroglycerin
applied to inguinal skin q 6 hours, diltiazem 7.5mg TID, Lasix 1-2mg/kg PRN to attain a RR
of 40 breaths/minute, also enalapril and aspirin to be commenced tomorrow. |
| A: Hypertrophic cardiomyopathy with secondary pulmonary edema is confirmed. The Lasix
will help to ease her breathing through vasodilatory, bronchodilatory, and more
importantly, diuretic effects. The diltiazem will help to relax the myocardium, slow the
heart rate, and allow better filling. |
| P: Transfer to Cardiology Service this afternoon. Keep on O2 and continue medications. |
Comments (Cardiology Service)
| ECHO: Severe HCM, with marked concentric LV hypertrophy, and severe left atrial
dilatation. Systolic anterior motion of the mitral valve is present at all times,
but the LVOT velocity is only 3 meters/second. Mild pleural effusion is also
present. Radiographs: severe pulmonary edema, diffuse lobar involvement. The RR was
only coming down slowly, so a 4 mg/kg dose was given s/c at 1 PM. This resulted in a
decrease in RR to 30 breaths/minute. Minimal Lasix was required after this dose. Follow-up
radiographs 24 hours later showed no remaining pulmonary edema (see below). Respiratory
rate was 36 at discharge. Following diuresis, the BUN was 40, and creatinine 2.7, so we
will attempt to control the pulmonary edema with low-moderate dose maintenance Lasix
therapy. |
Discharge Instructions
| Thank you for bringing Alice to the UC Davis Veterinary Teaching Hospital. |
| Alice
has a progressive heart disease called hypertrophic cardiomyopathy (HCM). Her respiratory
difficulty was due to left heart failure causing fluid accumulation in the lungs. The
following medications will help reduce the clinical signs. |
| Medications: Enalapril: Please give one tablet (1mg) orally once a day. Lasix: Please
give one half tablet (6.25mg) orally twice a day. Diltiazem: Please give one fourth of a
tablet (7.5mg) orally three times a day. Aspirin: Please give one baby aspirin tablet
(80mg) orally once every three days. Note: The aspirin is not included in the
pharmaceuticals provided today. A script was written and you may pick this drug up at any
human pharmacy. |
| Monitoring: If Alice shows any signs of respiratory difficulty, increased respiratory
effort, or an increased sustained respiratory rate (greater than 35 breaths per minute at
rest) please contact us or your regular veterinarian. |
| Recheck: Please make an appointment for a one week recheck to evaluate her response to
her medications. |
Right lateral radiograph taken 24 hours after medical therapy for pulmonary edema was
instituted. The alveolar infiltrates seen at admission are gone. The lung fields are
normal.
Recheck Examination on 6/17/98
Radiographic Report:
| Today's study is compared with radiographs dated 6/12/98 representing a 5 day recheck.
There has been a progression of the amount of pulmonary interstitial infiltrates since the
previous study. Severity of the infiltrates is now similar to that noted on the initial
study dated 6/11/98. Persistent and static cardiomegaly is noted. |
Discharge Instructions:
| Thank you for bringing Alice to the UC Davis Veterinary Teaching Hospital. |
| Alice looks clinically normal today with a normal respiratory rate but the thoracic
radiographs revealed moderate pulmonary edema. For this reason the daily dosage of Lasix
will be increased. Blood was taken to evaluate the kidney function. They showed that the
BUN was normal (26) as was the creatinine (1.4). All electrolytes were also within normal
limits. |
| Medications: Lasix: Please give one tablet (12.5mg) twice a day. Maintain all other
medications as previously instructed. |
| Monitor: Please continue to monitor Alice for any respiratory difficulty. |
| Recheck: Due to the findings on today's radiographs and the increase in her Lasix
dosage we would like to see Alice back here in one week. |
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