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Cardiovascular Examination FormGreat Ape Heart ProjectPlease complete the following sections and submit with a copy of the echocardiogram by mail or email:Great Ape Heart Project, Zoo Atlanta, 800 Cherokee Ave. SE, Atlanta, GA 30315gahpinfo@GENERAL INFORMATIONTaxon: FORMCHECKBOX Bonobo FORMCHECKBOX Chimpanzee FORMCHECKBOX Gorilla FORMCHECKBOX Orangutan FORMCHECKBOX Other:Exam Date:Exam Institution:Supervising VeterinarianName: _____________________________Phone: _____________________________Email: _____________________________Sonographer (for this exam)Name: __________________________________Training (select one): FORMCHECKBOX Zoo Technician FORMCHECKBOX Zoo Veterinarian FORMCHECKBOX Professional Sonographer FORMCHECKBOX MD Cardiologist FORMCHECKBOX DVM Cardiologist FORMCHECKBOX Other __________________________________Reason for Exam (select one): FORMCHECKBOX Routine Physical FORMCHECKBOX Pre-shipment to: ___________________ FORMCHECKBOX Quarantine exam FORMCHECKBOX Suspected heart disease FORMCHECKBOX Previously diagnosed heart disease* FORMCHECKBOX Clinical Problem, reason: ______________________ FORMCHECKBOX Other: ___________________*Please include current medications and conditions on page 3.Ape Name: DOB:Sex: FORMCHECKBOX Female FORMCHECKBOX MaleInstitutional ID#:Studbook#:Weight (kg): Weight: FORMCHECKBOX Actual or FORMCHECKBOX EstimatedGeneral Information – complete this first page for all submissions.Echocardiogram Form – please provide this form to the person performing the echo so that they are aware of the measurements we are requesting. Ask for a copy of the echo performed (DICOM format) so that the measurements can be confirmed. We need both measurements as well as the echo in order to provide you with report feedback. Health Conditions/Medications – please list any conditions and medications for this ape.Body Assessment Form – please print this form and have someone collect the measurements during an anesthetized exam.Anesthesia / Electrocardiogram / CBC Chem – these may be submitted as attachments from your institution’s record keeping system.Blood Pressure Form – if blood pressure was recorded please fill out this form.Echocardiogram RELEVANT EXAM INFORMATION FORMCHECKBOX Anesthetized FORMCHECKBOX Awake FORMCHECKBOX Transthoracic FORMCHECKBOX TransesophagealEXAM START TIME:ECHO START TIME:MEASUREMENTS & CALCULATIONSIVS(d): cmLVID(d): cm LVPW(d): cmLA: cmAo: cmIVS(s): cmLVID(s): cmLVPW(s): cmRVID(d): cmRA: cm1Method of EF determination: FORMCHECKBOX M-mode/Teichholz FORMCHECKBOX Simpson's FORMCHECKBOX Visually Estimated%2If 2nd Method of EF determination: FORMCHECKBOX M-mode/Teichholz FORMCHECKBOX Simpson's FORMCHECKBOX Visually Estimated%3If 3rd Method of EF determination: FORMCHECKBOX M-mode/Teichholz FORMCHECKBOX Simpson's FORMCHECKBOX Visually Estimated%FS: %Other Measurements:DOPPLER ASSESSMENTVALVULAR REGURGITATIONMITRAL INFLOWMV FORMCHECKBOX None FORMCHECKBOX Trace FORMCHECKBOX Mild FORMCHECKBOX Mod FORMCHECKBOX SevE vel: m/secE/A:Peak vel: m/secMax grad: mmHgA vel: m/sec FORMCHECKBOX N/A - SummatedTV FORMCHECKBOX None FORMCHECKBOX Trace FORMCHECKBOX Mild FORMCHECKBOX Mod FORMCHECKBOX SevLV OUTFLOWPeak vel: m/secMax grad: mmHgPeak vel: m/sec FORMCHECKBOX Laminar flow FORMCHECKBOX Turbulent flowAV FORMCHECKBOX None FORMCHECKBOX Trace FORMCHECKBOX Mild FORMCHECKBOX Mod FORMCHECKBOX SevMax grad: mmHgPeak vel: m/secMax grad: mmHgRV OUTFLOWPV FORMCHECKBOX None FORMCHECKBOX Trace FORMCHECKBOX Mild FORMCHECKBOX Mod FORMCHECKBOX SevPeak vel: m/sec FORMCHECKBOX Laminar flow FORMCHECKBOX Turbulent flowPeak vel: m/secMax grad: mmHgMax grad: mmHgEXAMING INSTITUTIONS COMMENTS PERFORMING SONOGRAPHER OR CARDIOLOGISTS COMMENTS:Please attach a copy of any cardiac reports received and include a copy of the echo to confirm measurements. To be considered a complete exam submission, we request the following cardiac measurements: IVS(d), IVS(s), LVID(d), LVID(s), LVPW(d), LVPW(s), LA size, RVID(d) and one EF measurement. Without these measurements we cannot guarantee diagnostic feedback. Health Conditions / MedicationsPLEASE LIST ANY CONCURRENT HEALTH PROBLEMS:Description of Event/ConditionBody System:[select one]Date First Observed - End dateOutcome:[select one]NeurologicDermatologicCardiovascularRespiratoryGastrointestinalEndocrineReproductiveMusculoskeletalUrogenitalDentalOphthalmicOther:ResolvedOngoingAlive with sequelaeDead EuthanizedUnknown1.2.3.4.5.PLEASE LIST ANY MEDICATIONS AND TREATMENTS:Product Name (Generic or Brand)Start date – End dateDose and unitsFrequency and Route1.2.3.4.5.BODY MEASUREMENTS1. Bottom of back to crown of head:Circle one:cm - inches2. Bottom of neck (even with height of shoulders) to top of crown:Circle one:cm - inches3. Bottom of back to bottom of neck (even with height of shoulders):Circle one:cm - inches4. Underneath right armpit to underneath left armpit:Circle one:cm - inches5. Hips – Right above where the right leg meets the back when in a seated posture:Circle one:cm - inches6. Width of the back measurement at 2/3 the way down from the crown (1/3 above the rump):Circle one:cm - inchesBody Assessment (BMI)[FOR ALL SPECIES PLEASE AT LEAST ATTEMPT TO COLLECT THE FIRST MEASUREMENT REQUESTED DURING ANESTHETIZED EXAMS – Disregard this form for awake submissions]The reason we ask for all 6 measurements is in order to calculate a more accurate BMI assessment. This is based on research by Dr. Elena Less at Cleveland Metroparks Zoo.Anesthesia / Electrocardiogram / CBC Chem(check here FORMCHECKBOX if awake exam – you do not need to complete this form)[PLEASE SUBMIT YOUR INSTITUTION’S ANESTHESIA REPORT]ANESTHETIC PROTOCOL MAINTENANCE FORMCHECKBOX None FORMCHECKBOX Isoflurane FORMCHECKBOX Sevoflurane FORMCHECKBOX Other:Agent(s) ---------- PREMEDICATION ----- Dosage/Method Administered & Route------TimestampAgent(s) ---------- INDUCTION -------------- Dosage Dosage/Method Administered & Route------ TimestampAgent(s) ------ PRE-ECHO REVERSAL ----- Dosage Dosage/Method Administered & Route----- TimestampSUPPLEMENTAL AGENTS/DOSES (e.g., if additional drugs/doses were necessary)ELECTROCARDIOGRAM (check here FORMCHECKBOX if ECG not performed)Was a telemetry strip recorded: FORMCHECKBOX Yes FORMCHECKBOX NoInterpretation from: FORMCHECKBOX ECG observed during echocardiogram (on monitor) FORMCHECKBOX Documented ECG (attached) FORMCHECKBOX Normal sinus rhythm (if not, use remaining lines to describe abnormal ECG findings)QRS Duration: msecPR Duration: msecQT Duration: msecPlease attach a copy of the ECG if availableCBC Chem (check here FORMCHECKBOX if CBC Chem report is attached)Were any blood values abnormal/of concern: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX AWAKE BLOOD PRESSURE MEASUREMENT (within 1 week of echocardiogram and without sedation/induction or inhalant anesthesia) FORMCHECKBOX ANESTHETIZED BLOOD PRESSURE MEASUREMENTDevice Model & Cuff Size Used:Session Notes:Date: 1METHOD: FORMCHECKBOX Direct FORMCHECKBOX Indirect Oscillometric FORMCHECKBOX Indirect Doppler FORMCHECKBOX Indirect Stethoscope/ManometerCUFF SITE: FORMCHECKBOX Antebrachium FORMCHECKBOX Brachium FORMCHECKBOX Thigh FORMCHECKBOX Lower Leg FORMCHECKBOX Finger FORMCHECKBOX Other:TIME:(HR:MIN AM/PM)______:______SYSTOLIC/DIASTOLIC/MEANPULSE2METHOD: FORMCHECKBOX Direct FORMCHECKBOX Indirect Oscillometric FORMCHECKBOX Indirect Doppler FORMCHECKBOX Indirect Stethoscope/ManometerCUFF SITE: FORMCHECKBOX Antebrachium FORMCHECKBOX Brachium FORMCHECKBOX Thigh FORMCHECKBOX Lower Leg FORMCHECKBOX Finger FORMCHECKBOX Other:TIME:(HR:MIN AM/PM)______:______SYSTOLIC/DIASTOLIC/MEANPULSE3METHOD: FORMCHECKBOX Direct FORMCHECKBOX Indirect Oscillometric FORMCHECKBOX Indirect Doppler FORMCHECKBOX Indirect Stethoscope/ManometerCUFF SITE: FORMCHECKBOX Antebrachium FORMCHECKBOX Brachium FORMCHECKBOX Thigh FORMCHECKBOX Lower Leg FORMCHECKBOX Finger FORMCHECKBOX Other:TIME:(HR:MIN AM/PM)______:______SYSTOLIC/DIASTOLIC/MEANPULSE4 Nominal Session ValueMETHOD: FORMCHECKBOX Direct FORMCHECKBOX Indirect Oscillometric FORMCHECKBOX Indirect Doppler FORMCHECKBOX Indirect Stethoscope/ManometerCUFF SITE: FORMCHECKBOX Antebrachium FORMCHECKBOX Brachium FORMCHECKBOX Thigh FORMCHECKBOX Lower Leg FORMCHECKBOX Finger FORMCHECKBOX Other:TIME:(HR:MIN AM/PM)______:______SYSTOLIC/DIASTOLIC/MEANPULSE GAHP Blood Pressure Form ................
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