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Lethargy

Initial Evaluation: The patient presented for examination due to coughing more recently. Was at swim therapy after MPL surgery and therapist heard new heart murmur. PE grade 2/6 heart murmur, harsh lung sounds, moderate effort. The patient is on a grain free lamb and lentil diet. Current Medications: Lasix 20mg PO BID-TID (3-5mg/kg/day), Pimobendan 5mg in AM and 2.5mg in PM.

Ultrasound findings and recommendations from initial echocardiogram are as follows: Chronic degenerative valve disease causing moderate mitral and mild tricuspid regurgitation. Moderate LA dilation is noted, which is concerning for progression in the future. In this small breed with CVD, the systolic dysfunction is striking and unusual. Possible causes include secondary to grain free diet (taurine deficiency), infarct to the myocardial wall, or simply primary dysfunction. Given the recent information on grain free diets, first step is either submit a taurine level and/or change the diet and supplement taurine. Taurine-deficiency is the sole cause of treatable dysfunction, although this patient will still have underlying CVD. Certainly continuing Pimobendan is also recommended, for cardiac support. With moderate LA dilation, there is some risk for CHF, however it is unclear if the Lasix initiated was necessary at this phase. Use of an ACE-I is recommended for long term anti-fibrotic benefit. Further investigation into the cough is recommended through screening chest radiographs, as potentially simple cough suppression may benefit QOL. Finally, a cardiac tumor associated with the aortic root is also identified. The most likely tumor type given this location and the history is a chemodectoma, however other differentials cannot be ruled out. Chemodectomas are often incidental findings, only causing clinical signs if blood flow is obstructed, pericardial effusion occurs, or a metastatic lesion causing systemic issues. The prognosis with cardiac chemodectomas is fair, with a MST of 1-2 years. The limiting factor is often hemorrhage into the pericardium. Other sequelae include impingement of cardiac blood flow secondary to tumor growth, or metastasis to the thorax or abdomen. At this time this is considered an incidental finding, and is unlikely to be causing an clinical issues due to it’s small size.

Plan: Consider screening chest radiographs as discussed. Consider hydrocodone if needed. If no h/o CHF or current concern, consider wean to lower dose: Give 15mg PO q12h. Continue Pimobendan as prescribed. Institute Benazepril 5mg PO q12h. Consider submit taurine levels and/or supplement taurine twice daily. Change to commercial non-grain free diet.

Patient presented 8 months later for lethargy. Current medications: Benazapril 5mgs twice daily, Pimobendan 5mgs a.m. and 2.5mgs p.m., Lasix 10mgs p.m. Blood pressure was 160mmHg. A recheck echocardiogram was performed.

A 13-year-old MN Pit Bull terrier was presented for evaluation of vomiting, diarrhea, lethargic, and weight loss.  Abnormalities on physical examination were dental tartar and possibly a heart murmur.

A 10-year-old FS Australian Shepherd was presented for evaluation of acute hematemesis, vomiting, diarrhea, and lethargy.  Abnormalities on physical examination were lateral recumbence, dehydration, and pyrexia (106.8).  Blood work showed thrombocytopenia and elevated ALT (655) activity. On survey radiographs possible mass in mid abdomen and hepatomegaly was evident.

A 2-year-old MN DLH cat presented for lethargy. CBC/Chem/UA showed BUN of 41, urine specific gravity 1.041, 2+ proteinuria, urine culture (+) for Staphylococcus. Generalized cardiomegaly was noted on radiographs in addition to subnormal renal size.

Hx of TTA performed on both knees. The patient was presented for a mass seen on the right knee. Owner reported the patient seemed more tired and not motivated for walks; limping on right hind limb. Examination of the right leg found a 15 cm invasive mass at the knee. The patient was placed on NSAIDS and scheduled for further diagnostics. CBC/Chem was WNL. 

The patient was presented for intermittent lameness of the left hind for a duration of 1.5 years. Recently the right hind limb is painful, the patient seems more lethargic and does not get up much. Radiographs from previous vet showed mild inflammation of the fat pad of the left stifle. Currently on Rimadyl. Physical exam found no cranial drawer. CBC, blood chemistry, and T4 were all WNL.

A 5-year-old male German shepherd was presented for evaluation of progressive pain, lethargy, anorexia, and hunched back following an episode of abdominal trauma - tried to jump over a large hole and hit his abdomen on the edge of the hole.

 12-year-old MN Labrador mixed breed was presented for evaluation of anorexia, vomiting, and lethargy. Abnormalities on CBC and serum biochemistry were severe leukocytosis,neutrophilia, hemococentration, and elevated ALP (600).

An 8-year-old F Maltese was presented for examination.  A grade 5/6 systolic heart murmur was noted. Radiographs revealed severe generalized cardiomegaly and an unremarkable pulmonary parenchyma. Moderate hepatomegaly and ascites was additionally noted.