Medical Summary
Date: July 3, 2024
Overview: This document summarizes the available medical records for {Patient1}, a 7-year-old Pomeranian, focusing on her chronic conditions, recent diagnostic findings, and ongoing treatment plans. {Patient1} has a complex medical history involving cardiac, neurological, dermatological, and dental issues.
Key Medical Issues:
- Cardiac Disease:Diagnosis: Degenerative Mitral Valve Disease, ACVIM Stage B2. Mild Tricuspid and Aortic Valve Disease. Progression noted in November 2023.
- Findings: A heart murmur has been consistently noted, ranging from Grade III/VI to Grade IV/VI, and occasionally Grade 2.
- Echocardiograms reveal mitral valve thickening with mild to moderate regurgitation, mild left atrial enlargement (The left atrium is mildly enlarged (LA:Ao 1.72 avg Swedish), improved compared to previous evaluation.). The left ventricular internal diameter is mildly dilated.
- Medication: Pimobendan (1.25mg 1/2 tablet q12).
- Altitude can worsen heart disease.
- Neurological Issues:Diagnosis: Chiari-like malformation with syringohydromyelia of cervical/cranial thoracic spinal cord and IVDD.
- Findings: Occasional “honking cough.” Neurological exams have been generally normal, with no ataxia or weakness noted.
- Medication: Omeprazole oral suspension (2mg BID). Prednisone (0.625mg every other day).
- Dermatological Issues:Diagnosis: Truncal alopecia, most prominent on the hind end.
- Gastrointestinal Issues:History: Several-year history of infrequent episodes of borborygmi and mucous associated with normal stool.
- Urinary Issues:History: UA in April-May 2023 showed a mildly elevated WBC count and evidence of cocci bacteria.
- Findings: Some crystals noted, but not initially concerning. No lower urinary tract signs reported.
- Dental Issues:Findings: Mild dental tartar and gingivitis. Uncomplicated tooth fracture at the left maxillary fourth premolar (208). Oligodontia (missing teeth).
- Weight Fluctuations:Weight has fluctuated. Was 2.01 kg in Dec 2023, down to 1.78 kg by June 2024.
Recent Diagnostics & Results:
- Cardiac Evaluation (May 21, 2024):Heart rate: 90 bpm, Regularly irregular, Grade III/VI systolic regurgitant type left apical heart murmur.
- “The left atrium is mildly enlarged (LA:Ao 1.72 avg Swedish), improved compared to previous evaluation.”
- “The mitral valve is thickened with mild prolapse causing mild-to-moderate regurgitation.”
- “Degenerative Mitral Valve Disease – ACVIM Stage B2 – Improved”
- “Degenerative Tricuspid Valve Disease – Static/Mild”
- “Degenerative Aortic Valve disease – MIld”
- In-House Blood Work (Apex, Sept 28, 2023):Elevated glucose (127 mg/dL; reference range 80-110 mg/dL).
- Normal blood parameters within reference ranges.
- Diagnostics (June 20, 2023 and December 6, 2023 and June 4, 2024):Elevated glucose on 6/20/23 (131 mg/dL, reference 74-143) but normal on 6/4/24 (111 mg/dL, reference 70-143).
- Elevated cholesterol on 6/20/23 (279 mg/dL, reference 110-320) and 12/6/23 (350 mg/dL, reference 131-345). Lower on 6/4/24 (213 mg/dL, reference 110-320).
- Creatinine consistently on the low end of the normal range (0.4-0.5 mg/dL).
- “SDMA is within the reference interval and creatinine is low: impairment of GFR is unlikely.
- CBC results generally unremarkable.
- T4 levels within normal range (1.2 to 1.6 µg/dL).
- Diagnostics (June 7, 2024):“Platelets appear increased.” (605 K/uL, reference 143-448)
- “NRBC 4HIGH 0-2 per 100wbc”
- “HGB 13.1LOW 13.4-20.7 g/dL”
- Cholesterol 269 131-345 mg/dL
- Urinalysis (Alpine, various dates in April-May 2023):USG consistently high (1.048 – 1.056).
- Evidence of bacteria (cocci) and WBCs at times, suggesting possible UTI, but patient is asymptomatic.
Current Medications & Diet:
- Proviable (1 capsule daily)
- Prednisone (0.625mg every other day)
- Omeprazole (2mg BID)
- Ursodiol (31.25 mg PO q24h)
- Pimobendan (1.25mg 1/2 tablet q12)
- Metamucil (1 capsule q2
- Diet: Royal Canin HP wet and dry and Hills I/D low fat wet and kibble.
Ongoing Management & Plans:
- Cardiac: Continue Pimobendan, monitor for signs of CHF (coughing, panting, increased respiratory effort).
- Neurological: Continue Prednisone and Omeprazole.
- GI: Continue Royal Canin HP. Monitor for recurrence of GI upset.
- Urinary: Monitor for signs of UTI.
- Dental: Regular dental care, including professional cleanings and home dental hygiene.
- General: Recheck CBC/chemistry every 6 months.
Concerns & Questions:
- Dental Procedure: The records indicate that the owner is considering a dental procedure. Given {Patient1}’s cardiac condition, a cardiology consult is recommended prior to any anesthetic procedure.
- Weight Loss: {Patient1}’s recent weight loss should be monitored.
- High Platelet Count: Platelet count should be monitored
Summary:
{Patient1} is a senior dog with several chronic conditions that require ongoing management. Her cardiac disease is a primary concern, requiring medication and monitoring. Dental health is also a key issue, and any planned procedures should be carefully coordinated with a veterinary cardiologist. The neurological and dermatological conditions are being managed with medication and diet, respectively. Regular monitoring of blood work and urine is essential to detect any changes in her condition.
