C10002754 / invoice 10000

Reason: (Progress Examination)

Consult Nurse: (KM)

History:
Current medications:
-   Compounded capsule containing Pimobendan 1.75 mg, Benazepril 2.5 mg, and Furosemide 12 mg, administered twice daily.
         +   PLUS Frusemide 10mg BID
         Total frusemide dose = 44mg/day (6.5mg/Kg)
-   Beransa 5 mg, last given on 11/02/2026.
-   Cortavance in ear canals a couple of times per week after Otoflush cleaning.

SRR was over 60 bpm late last week, now sitting in the 50s most of the time.
Owner dropped frusemide from total 9.5mg/Kg/day to 6.5mg/Kg/day under vetereinary direction.


Physical Exam:
BAR; ()
Behaviour: ()
HR: (180); RR: (48);  T: (37.6); MMC: (light pink and tacky); CRT: (2sec);
Hydration (normal)
Cardiac (grade 5/6 murmur auscultated, radiates widely in the chest - crackles not auscultated, but murmur is loud and definitely obsceures resp sounds)
Abdo (NSF)

Reccommended repeat chest radiographs to check pulmonary oedema resolution - owner consented

Radiographs show pulmonary oedema is improved since Thursday, but not totally resolved.

Client Communication from Vet:
(Spoke to Dr Richard - discussed ongoing treatment, and advice was to add a third daily dose of Pimobendan (another 0.25mg/Kg) at lunchtime; use the highest dose of frusemide tolerated by Maxie to control his SRR; add spironolactone SID.

Spoke to owner - discussed Maxie - discussed benefit of monitoring SRR and using this as the most sensitive indicator for diuretic dose adjustment - owner will recheck it tonight - then she is away for the weekend - and recheck it again when she is back on Monday. Owner can report SRR to me weekly and we can adjust frusemide dose rates based on these SRR.

Advised of the below dose rate adjustments - owner agreed and will have the frusemide dose adjusted and the spironolactone added today; and will add the lunchtime dose of Pimobendan on Monday when she gets home from being away.

Discussed survival time is very hard to estimate; but monitoring of SRR and response to diuetic medications will be the best monitoring tool we have.)

Assessment/Updated problem list:
(Ongoing CHF with ruptured cordae tendinae - improvement in SRR and pulmonary oedema in the recent days, but not resolved)

Treatment:
New cardiac medication list:
-   Compounded capsule containing Pimobendan 1.75 mg, Benazepril 2.5 mg, and Furosemide 12 mg, administered twice daily
-   Frusemide 15mg PO morning and night (3/4 of a 20mg tablet)
-   Spironolactone 12.5mg PO in the evenings (1/2 of a 25mg tablet)
-   Pimobendan 3.5mg/mL liquid (owner has at home) 1.75mg (0.5mL PO at lunchtime)

Dose rates:
Frusemide: 4mg/Kg PO BID (8mg/Kg/day) --- we can go up to 12mg/Kg/day if we need to, but risk renal disease --- a risk worth taking if the pulmonary oedema worsens and QOL declines
Benazepril: 0.35mg/Kg PO BID
Pimobendan: 0.25mg/Kg PO TID
Spironolactone: 2mg/Kg PO SID

Plan:
(Owner to report SRR to me early next week - adjust diuretic dose rate based on SRR)

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Summary
This summary outlines the changes we are making to Maxie's medication for his congestive heart failure.  
  
As you know, Maxie has been under treatment for congestive heart failure since January. The chest x-rays we took last week showed an increase in the amount of fluid on his lungs (pulmonary oedema). After a short course of increased medication, we rechecked him today. His examination and new x-rays showed that the fluid has continued to decrease, which is great news, but there is still oedema present.  
  
After discussing his case with an internal medicine specialist, we have decided to adjust his medications to better manage the fluid and support his heart. We will be increasing his diuretic (fluid tablet) dose, adding a new type of diuretic, and also adding a lunchtime dose of his main heart medication, Pimobendan. The goal of these changes is to further reduce the fluid on his lungs and improve his overall comfort.  
  
The most important thing for you to monitor at home is his sleeping respiratory rate (the number of breaths he takes in one minute while fast asleep). Please check this tonight. Your mum can continue the new medication schedule over the weekend while you are away. When you return, please check his sleeping respiratory rate again on Monday or Tuesday. We will then have a chat mid-next week to see how he is travelling on the new doses.  
  
We are here to support you and Maxie, so please don't hesitate to reach out if you have any questions or concerns.

Key Findings
Test Results:
-   Chest x-rays: Showed a further reduction in pulmonary oedema (fluid on the lungs), however, a small amount is still present, mostly in the perihilar region.
  
Diagnoses and Conditions:
-   Congestive heart failure
-   Pulmonary oedema

Treatment Plan & Care Instructions
Medications Sent Home:
-   Triple Compounded Medication (Pimobendan 1.75 mg, Benazepril 2.5 mg, Frusomide 12 mg): Continue to give 1 capsule by mouth twice a day (morning and night).
-   Pimobendan (Vetmedin liquid): Give 0.5 mL by mouth at lunchtime each day. This can be given on a small amount of food.
-   Frusomide (20 mg tablets): Give an additional three-quarters (3/4) of a tablet by mouth twice a day (morning and night). This is given on top of the Frusomide in his compounded medication.
-   Spironolactone (25 mg tablets): Give half (1/2) a tablet by mouth once a day in the evening. A prescription will be provided for you to have this filled at a pharmacy.
  
Other Treatments and Home Care Instructions:
-   Sleeping Respiratory Rate Monitoring: This is of the highest importance. Please count the number of breaths Maxie takes in one minute while he is sound asleep. A normal rate is less than 30 breaths per minute, but I do not expect his to be that low.
-   Please perform a sleeping respiratory rate count this evening.
-   Please perform another count on Monday or Tuesday of next week and report to Dr Abby.

Signs to Watch For
-   Increased breathing rate or effort, especially when resting or sleeping
-   Worsening cough, especially at night
-   Lethargy or weakness
-   Decreased appetite

Follow-up Steps
-   We will contact you mid-next week to discuss how Maxie is responding to the medication changes.
-   We plan to recheck his blood tests (electrolytes) next week to ensure the increased diuretic dose is well-tolerated.
-   Please contact us immediately if you notice his breathing worsen or if you have any other concerns.