Sunday, February 1, 2009

matters of the heart

as the dog crept toward me, i started my list of physical exam findings: extremely poor body condition (ribs were prominent, vertebral spines very noticeable) but a distended/pendulous abdomen, increased respiratory rate and effort, stiff gait, and a generally unhealthy look were all too evident.

as i glanced at the record, i was stunned to see that the once beautiful male german shepherd before me was a mere 6 years old. he looked and acted at least 12.

he was a very sweet boy with big, expressive brown eyes. as i placed the nasal oxygen prongs in his nose, he gave a big sigh and laid his head on my knee.

as i examined him, i added to my physical exam list: mild heart murmur, louder on the right side of the heart, increased lung sounds, and severe abdominal distention with a fluid wave (when i briskly tapped his abdomen with a finger, fluid was felt).

everyone around me (techs, other doctors) were insisting that he had a hemoabdomen (blood in his abdomen) and a likely hemangiosarcoma (splenic tumor). looking at him, i doubted this. he was in generally poor condition.

i held off making a judgement until i could quickly tap his abdomen with a needle and remove fluid. sure enough - not blood. it was a clear, yellowish fluid with a tinge of pink. i turned to my technician. "would you please ask this owner if this dog is kept on heartworm preventative?"

the answer was really all the answer i needed. no, the dog was not on heartworm preventative. we ran the test. it was a strong positive. looking at a blood smear revealed greater than a 100 microfilariae (immature heartworms) swimming in the blood.

heartworms mature in the heart, notably the right side. that side of the heart is responsible for taking the blood back from the rest of the body and circulating it through the lungs for oxygen exchange. when the heartworms interfere with this, the heart goes into right-sided failure. fluid backs up into the body, mostly the liver, and that increased pressure causes fluid to leak out of the vessels - serum, plasma, and proteins. this fluid builds up in the belly - called ascites. there are other causes for ascites, but given that this dog was not on heartworm preventative and had respiratory signs - heartworm was number one on the list.

i talked to the owners. treatment of this dog would focus on getting him out of heart failure with lasix to decrease the ascites, heart failure medications, and supportive care. once he was out of failure, we could treat the heartworms. we were easily looking at spending $2000.

the owners didn't have that money. they had adopted the dog a mere 2 weeks beforehand from an elderly grandmother. euthanasia was their decision. they kissed him goodbye, and i took him to the back.

we gave him some yummy wet food, which he slowly ate. then, while my technician held his head and told him he was a good boy (which he most certainly was), i did that thing which i do 30 times a month but hate most.

he went with a quiet sigh, closely his doggy brown eyes and simply going to sleep.

and all of this could have been prevented with simple monthly chewable tablets.

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