C09990180 / invoice 10000

HISTORY:
Presented for:

EXAM:
Mentation:
BCS:
Hydration status:
Eyes:
Ears:
Nose:
Mouth:
MM:
Throat:
LNs:
CV: HR:
Resp:
Abdo:
MSK:
Integ:
Neuro:
Genitourinary:
Rectal:
T:

ASSESSMENT:

PLAN:

COMMUNICATION:

HISTORY:
Presented for echo; recently auscultated murmur
Well at home, breathing normally

EXAMINATION:
*DOG REACTIVE* but O reports good with people
BAR, BCS 6/9, T not taken
Eyes NAD
Ears NAD
Oral mild tartar and gingivitis
MM pink, CRT 1.5s
HR 120, grade III/VI murmur
RR 20, NAD
Abdomen comfortable
LN WNL
Integ NAD

ECHOCARDIOGRAM
Sedation: butorphanol 0.72ml IV, insufficient sedation so administered further butorphanol 0.35ml IV, still insufficient sedation so administered ACP 0.18ml IV
Report:
B-mode (each figure averaged over a minimum of 3 measurements, unless otherwise specified)
LA (LAx) 39.8 mm
Ao (LAx) 19.1 mm
LA:Ao (LAx) 2.08 (normal <2.6)
LA (SAx) 27.15 mm
Ao (SAx) 20.67 mm
LA:Ao (SAx) 1.31 (normal <1.6)
PA:Ao approx 1:1

M-mode (each figure averaged over a minimum of 3 measurements, unless otherwise specified)
IVSd 13.16 mm
LVIDd 48.86 mm
LVPWd 11.23 mm
IVSs 17.86 mm
LVIDs 34.73 mm
LVPWs 15.1 mm
FS 28.9 %

Doppler
PA Vmax 0.64 m/s (normal <1.4 – 1.8)
Ao Vmax 0.76 m/s (normal <2)
MR Vmax unable to measure (suboptimal alignment, and jet quite small)

Sonographic findings:
- normal left atrial size and normal LA/Ao
- mild mitral regurgitation
- mitral valve thickening with no prolapse
- very mild left ventricular dilation during diastole and systole
= Stage B1 myxomatous mitral valve disease (MMVD)

Comments:
The findings are consistent with stage B1 MMVD. No medications are currently indicated. Ongoing monitoring of resting respiratory rate is recommended (normal is <30 breaths per minute, obtained when patient is calm or asleep). A repeat echo is recommended in 6-12mths, sooner if clinically indicated (e.g, increased respiratory effort, increased respiratory rate, coughing, reduced exercise tolerance).

TREATMENT/ TREATMENT PLAN:
Nil

COMMUNICATION:
1545 SZ STO with update and discussed findings as above; no meds currently indicated
1800 SZ realised at discharge forgot to obtain pre-GA bloods - expressed my sincere apologies; Os very gracious; took it very well and were unbothered

SUBJECTIVE:
Had surgery prior this year. On gabapentin and trazodone
New Year eve fireworks.
Also warts to be examined. 
Squeeze anal glands

OBJECTIVE:
T 38.6 HR 120 Grade 3 murmur.
MM pink CRT < 2sec

ASSESSMENT:
Heart murmur- needs echo
Continue Apoquel. 

PLAN:
Kalma 4 mg prior tpo FW

CLIENT COMMUNICATION:
Medicate as direcdted. Can give additional gaba If Kalma not eniough.