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[MAPLEWOOD VETERINARY CLINIC LETTERHEAD] Maplewood Veterinary Clinic 482 Elmwood Drive Burlington, VT 05401 Phone: [Clinic Phone] [Date] [Specialist Veterinarian Name, DACVIM – Cardiology] [Specialty Practice Name] [Address] [City, State ZIP] Phone: [Practice Phone] RE: REFERRAL – BISCUIT (Canine) – Suspected Cardiac Disease / CHF Patient ID: [Clinic Patient ID] Referred by: Dr. Sandra Keene, DVM, Maplewood Veterinary Clinic Owner: Margaret Holloway Contact: [Owner phone/email] --- Dear [Specialist Name]: I am referring my patient, Biscuit, a 7-year-old male neutered Golden Retriever weighing 34.2 kg, for comprehensive cardiologic evaluation. Biscuit presents with clinical and radiographic evidence of suspected structural cardiac disease with secondary left-sided congestive heart failure. I am requesting your expertise in characterizing the underlying etiology (dilated cardiomyopathy vs. degenerative mitral valve disease), assessing myocardial function via echocardiography, and optimizing long-term medical management with the owner. CLINICAL PRESENTATION History: Biscuit presented to my clinic approximately 3 weeks ago with a 6-week history of progressive exercise intolerance, intermittent coughing (worse at night), and significant weight loss (2.1 kg over 2 months). The owner reports reduced appetite and occasional episodes of labored breathing at rest. No prior cardiac history is documented. Biscuit is currently on no medications. Vaccinations and heartworm prevention are current. Physical Examination (Initial Presentation, [Date]): - Heart: Grade IV/VI systolic murmur at the left apical location; muffled heart sounds noted on ventral auscultation - Jugular Veins: Bilateral jugular vein distension present - Mucous Membranes: Pale pink - Capillary Refill Time (CRT): 2.5 seconds (delayed; normal ~1–2 sec) - Abdomen: Mild ascites detected on palpation - Respiratory: No abnormal lung sounds; RR and effort not specified; [verify respiratory parameters] - General: [Alert and responsive; general demeanor not detailed] DIAGNOSTIC FINDINGS 1. THORACIC RADIOGRAPHS (04/28/2025 – 3 views): • Marked cardiomegaly with Vertebral Heart Score (VHS) 11.8 [normal <10.5–11.0] • Moderate pleural effusion bilaterally • Pulmonary venous congestion consistent with left-sided CHF • No pneumonia or other concurrent pulmonary pathology noted 2. LABORATORY RESULTS (04/28/2025): • CBC: Mild non-regenerative anemia [HCT value not specified – verify] • Chemistry Panel: - Pre-renal azotemia: BUN 38 mg/dL (normal ~7–27 mg/dL); Creatinine 1.9 mg/dL (normal ~0.9–1.6 mg/dL) - ALT elevated: 78 U/L (normal ~10–40 U/L) — consistent with hepatic congestion secondary to right-sided failure - Electrolytes: Within normal limits • Coagulation Panel: Prothrombin time and aPTT within normal limits • Heartworm antigen: Negative (04/28/2025) 3. BLOOD PRESSURE (Doppler method, [date not specified]): • Systolic/Diastolic: 148/92 mmHg [mild elevation; verify reference range and concern for secondary hypertension] 4. ELECTROCARDIOGRAM (In-clinic, [date not specified]): • Sinus tachycardia: 148 bpm (normal ~60–100 bpm) • No arrhythmias detected • [ECG axis, QRS duration, and other intervals not detailed – request original tracing if available] CLINICAL INTERPRETATION The clinical, radiographic, and laboratory findings are consistent with congestive heart failure secondary to structural cardiac disease. The left apical systolic murmur, marked cardiomegaly, pulmonary venous congestion, pleural effusion, elevated filling pressures (JVD, ascites), and secondary organ dysfunction (pre-renal azotemia, hepatic congestion reflected in elevated ALT) all support a diagnosis of left-sided heart failure. The etiology (DCM vs. DMVD with secondary remodeling) requires echocardiographic characterization. REFERRAL QUESTIONS & OBJECTIVES 1. Characterization of Underlying Cardiac Disease: • Is the primary lesion dilated cardiomyopathy (DCM) with reduced systolic function, or degenerative mitral valve disease (DMVD) with secondary chamber remodeling? • What is the degree of systolic and diastolic dysfunction? 2. Assessment of Myocardial Function: • Echocardiographic assessment of left ventricular ejection fraction (LVEF), fractional shortening (FS), left atrial-to-aortic root ratio (LA/Ao), and other relevant dimensional and functional parameters • Mitral regurgitation severity (if present) and degree of left atrial enlargement • Right-sided chamber dimensions and function given evidence of right-sided failure 3. Medical Management Optimization: • Recommendations on initiation and dosing of cardiac medications, including: - ACE inhibitor (enalapril or similar) - Positive inotrope: Pimobendan (if indicated for systolic dysfunction) [verify [drug class — verify] and indication] - Diuretics: Furosemide dosing and frequency for fluid management - Other agents (beta-blockers, aldosterone antagonists) as appropriate [verify indication] • Monitoring parameters and laboratory follow-up schedule • Diet and sodium restriction recommendations 4. Prognosis and Owner Communication: • Long-term prognosis and expected timeline for disease progression • Quality-of-life considerations and owner expectations • Discussion points for the owner regarding disease course, medication adherence, and palliative vs. aggressive management SPECIAL CONSIDERATIONS • Pre-renal azotemia and mild anemia suggest compromised renal perfusion secondary to low cardiac output; baseline renal function must be monitored closely with diuretic therapy • Elevated ALT reflects hepatic congestion; this should improve with optimal diuretic dosing but requires monitoring • Mild systemic hypertension (148/92) may complicate management; antihypertensive therapy should be carefully balanced against need for adequate systemic perfusion pressure [verify pharmacology and contraindications] • Pleural effusion and respiratory signs warrant monitoring for worsening pulmonary edema; diuretic response should be assessed within 5–7 days of therapy initiation [per veterinarian order/facility protocol] CURRENT MEDICATIONS & BASELINE STATUS • No medications initiated at this time pending your evaluation and recommendations • Patient has no documented drug allergies [not provided — verify] PLEASE CONTACT ME I am available to discuss any questions regarding this patient or to coordinate follow-up care. Please feel free to contact me directly at [clinic phone] or [email]. Thank you for accepting this referral and for your expertise in managing this complex case. Sincerely, [Dr. Sandra Keene, DVM] Maplewood Veterinary Clinic Burlington, VT 05401 Phone: [Clinic Phone] [DVM Signature] ENCLOSURES: • Copies of radiographic reports and images • Laboratory results (CBC, chemistry panel, coagulation studies) • ECG tracing (if available) • Owner contact information and authorization for communication

CLINICAL SUMMARY FOR SPECIALIST REFERENCE PATIENT: Biscuit | Golden Retriever, 7-year-old male neutered, 34.2 kg OWNER: Margaret Holloway | REFERRING DVM: Dr. Sandra Keene, Maplewood Veterinary Clinic, Burlington, VT PRESENTING PROBLEM: 6-week history of progressive exercise intolerance, nighttime cough, 2.1 kg weight loss, reduced appetite, and episodes of dyspnea at rest. No prior cardiac disease. KEY CLINICAL FINDINGS: • Grade IV/VI left apical systolic murmur • Jugular vein distension (bilateral) • Delayed CRT (2.5 sec) and pale mucous membranes • Mild ascites on palpation • Muffled heart sounds ventrally KEY DIAGNOSTIC FINDINGS: • Radiographs: Marked cardiomegaly (VHS 11.8), moderate bilateral pleural effusion, pulmonary venous congestion consistent with left-sided CHF • Labs: Mild pre-renal azotemia (BUN 38, Cr 1.9), elevated ALT 78, anemia (HCT not specified), normal coagulation, negative heartworm • ECG: Sinus tachycardia 148 bpm, no arrhythmias • BP: 148/92 mmHg (slightly elevated) CLINICAL DIAGNOSIS: Left-sided congestive heart failure secondary to structural cardiac disease (DCM vs. DMVD with remodeling — etiology to be determined by echocardiography). REFERRAL GOALS: Echocardiographic characterization of cardiac structure and function; differentiation between DCM and DMVD; optimization of medical management (ACE inhibitor, Pimobendan, Furosemide dosing); and discussion of prognosis with owner. CRITICAL MONITORING POINTS: • Renal perfusion and azotemia (pre-renal in origin) — may worsen with diuretic therapy; baseline monitoring essential • Hepatic congestion secondary to right-sided failure — ALT elevation reflects congestion, should improve with optimal diuretics • Respiratory status — monitor for worsening pulmonary edema; diuretic response expected within 5–7 days • No medications initiated pending specialist evaluation and recommendations