Signalment: 7-year old female Golden retriever
	History: Polyuria and polydispia present for 6-8 weeks but much more severe during the past 2 weeks. Dog in estrus 4-5 weeks ago. Five days prior to admission, vomiting 4-5 times a day and appetite is very poor. For the past 48 hours, dog has been very depressed. Dog has been 15-20% overweight for the past 2 years. Dog is well vaccinated and receives monthly heartworm preventative. Diet is premium dry dog food and table food. 2 years ago, another veterinarian tested thyroid function and it is reported as normal. The dog tested positive for anti-T4 and anti-T3 antibodies but was negative for anti-thyroglobulin antibodies.
	Physical Examination: T. 103.5F, HR 70, RR rapid and shallow, MM are brick red, and CRT is <2.0 seconds. The pulse is thready. Dog is depressed and 10-12% dehydrated. Ausculatation reveals a grade III holosystolic murmur with PMI at 4th intercostal space at costochondral junction. The abdomen is distended and the dog grunts when the abdomen is palpated. The vulva is enlarged and no vaginal discharge is noted. Rectal palpation produces dark black, soft feces. There are tiny red spots on the abdominal skin and vulvar mucosa. The peripheral lymph nodes are normal.
	Diagnostic Plan:Using the POVMR format, identify the problems and formulate a diagnostic plan for this case.

A. List the problems you have observed.

No.	Problem
1.	VOMITING with ANOREXIA, DEHYDRATION AND DEPRESSION
2.	POLYURIA/POLYDISPSIA
3.	DISTENDED and POSSIBLY PAINFUL ABDOMEN
4.	PETECHIA
5.	BRICK RED ORAL MUCOSA
6.	DARK SOFT FECES
7.	GRADE 3 SYSTOLIC HEART MURMUR
8.	THREADY PULSE
9.	TACHYPNEA

B. Of the problems you have identified, which is (are) the most important to manage?
ALL OF THE PROBLEMS ARE IMPORTANT 
BUT 1, 2 AND 3 ARE THE MOST IMPORTANT

A. DX: List ruleouts for the problems you identified in Step 2.
Problem No.	Ruleout(s)
1.	PRIMARY GI: Acute pancreatitis; liver disease; gastroenteritis; peritonitis; GI obstruction. METABOLIC CAUSES: Renal failure; pyometra; hypoadrenocorticism; diabetic ketoacidosis.
2.	Renal disease/failure; diabetes mellitus; pyometra; hyperadrenocorticism; diabetes insipidus; hypercalecmia; psychogenic polydipsia.
3.	Fluid/peritoneal effusion/ascites/peritonitis; organomegaly (pyometra, hepatomegally, spleen; fat; neoplasia, air.
4.	thrombocytopenia; vasculitis
5.	Hyper-perfusion (sepsis, toxemia); polycythemia; gingivitis/stomatitis
6.	Upper GI hemorrhage (ulceration, thrombocytopenia, coagulation disorder)
7.	Endocardiosis; valvular endocarditis; cardiomyopthy; anemia
8.	Decreased cardiac output/hypotension
9.	Acidosis; primary respiratory disease (aspiration pneumonia)

B. List those diagnostic procedures that will be most cost-effective.

1.	Hemogram
2.	Urinalysis
3.	Biochemical Profile
4.	Abdominal and thoracic radiographs

4. Assessment & Follow-up

Analyze the initial database results.

Hematology:

RBC Morphology:

Test	Value	Unit	Point your mouse here to view Hematology Norms	Test	Value
WBC	32.5	x 103 /mm3		Normal	Hyperlipemia
RBC	8.5	x 106 /mm3		Rouleaux	none
HGB	22	g/dl		Polychrome	none
PCV	60	%		Aniso	none
MCV	65	fl		Poik	none
MCV	24	pg		Crenation	none
MCHC	36	g/dL		Target	none
PLT	80	x 103 /mm3		Hypochrome	none
TP	8.5	g/dL		BasoStip	none
FIB	500	mg/dL		Sphero	none
Retic	0	%		NRBC/100 WBC	none
PUNT
AGGR
SED RATE		x 103 /mm3

Differentials:

Assessment: What is your assessment of the hematology data?

Test	%	Absolute	Point your mouse here to view Hematology Norms	Neutrophilic leukcytosis with left shift. Hemoconcentration (increased PCV and total protein). Thrombocytopenia is present but not sufficient to explain petechia. Should suspect vasculitis as cause of petechia. Hyperlipemia indicates a metabolic disorder of fat. The hemogram is strongly indicative of SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS). Pyometra, urinary tract infection, pancreatitis and sepsis should be ruled out.
SEG		25000
Band		2000
Lymph		2000
Eosin		1000
Mono		3000
Baso		0
Other		0
PLTest
Toxic change

Biochemical profile:

Test	Value	Unit	Point your mouse here to view Chemistry Norms	Test	Value	Unit
Sodium	132	m mol/L		T. Bili	1	mg/dl
Potassium	3.4	m mol/L		ALKP	160	u/l
Chloride	108	m mol/L		ALT	75	u/l
TCO2	10	m mol/L		AST		u/l
Urea	50	mg/dl		LDH		u/l
Creatinine	1.4	mg/dl		CK		u/l
Calcium	10	mg/dl		GGT		u/l
Phosphorus	2.4	mg/dl		Magnesium		mg/dl
Glucose	450	mg/dl		Osmolality		mosm/L
T. Protein	7.5	g/dl		Anion Gap		mosm/L
Albumin	5	g/dl
Globulin	2.5	g/dl
A/G ratio

What is your assessment of the biochemical profile ?

Diabetes mellitus and metabolic acidosis are present. Prerenal azotemia is present. Hyponatremia, hypochloremia and low normal potassium are likely caused by a combination of vomiting and polyuria. Mild increase in ALT, ALKP and bilirubin suggest concurrent cholestatic liver disease. These can occur in animals that are septic and in cases of acute pancreatitis.

Urinalysis:

Microscopic Sediment Exam:

Test	Value	Unit		Test	Value	Unit
Volume	10 ml	ml		WBC	20-30/hpf	ml
Color	pale yellow			RBC	3-4/hpf
Transparency	clear			Bacteria	1 +
Specific Gravity	1.028			Epitheliel	0
Phosphorus				Fat	2 +
Protein	1 +	mg/dl		Sperm	0
Ketones	3 +	mg/dl		CaOxalate	0
Bilirubin	1 +			CaCarbonate	0
Blood	1 +			TriplePhos	0
Urobili	1 +			Bilirubin	1 +	mg/dl
Glucose	4+			Amorph	0	mg/dl
				Casts	0

What is your assessment of the urinalysis data?

Despite obvious osmotic diuresis, dog is concentrating urine. Renal failure is not present but a UTI is present. Given the hematological findngs, pyelonephritis should be considered. The urine should be cultured.

Identify the major ruleout(s) supported by this data.

Pyometra, acute pancreatitis, pyelonephritis, sepsis. Diabetic ketoacidosis is confirmed.

Have you identified any new problems?	Yes	If so, what are they?
Yes: UTI, hyperlipidemia, SIRS, thrombocytopenia

List the diagnostic tests or procedures that should be performed next.

Abdominal radiographs, abdominal ultrasonography, urine culture, amylase, lipase, and clotting test (activated clotting time)

RX:

What immediate therapy would you prescribe for problems identified in Section 2?

1. Begin IV normal saline solution with potassium supplementation.  2. Begin IV or IM regular insulin.  3. Monitor blood glucose and urine ketones every 2-3 hours.  4. Begin parenteral antibiotics that cover gram negative organisms and anaerobes (enrofloxacin, metronidazole/penicillin).

Learning Issues:

	Describe the electrolyte and acid-base abnormalities that occur in diabetic ketoacidosis before and after treatment.
	Describe the pathophysiology of diabetic ketoacidosis.
	Describe the term "SIRS" and its relationship to disseminated intravascular coagulation.
	Describe the conditions that initiate ketoacidosis in diabetic dogs.
	Describe the diagnostic process for confirmation of acute pancreatitis

Continue with Expanded Case Evaluation

Problems? Content: Dr. Michael D. Lorenz; Web page operation: Betty Handlin
Copyright^© 1999 Oklahoma State University College of Veterinary Medicine
This page was last updated 10/19/07 09:51:09 AM