Case 3 Endocrinology Answers

Endocrinology Case 3

Expert's Answers

1. Data Base Collection

	Signalment: Feline domestic shorthair,10 years old, m/c
	History: One year ago cat developed miliary dermatitis and was treated with megesterol acetate at 5 mg orally twice a week for 6 months. Therapy was discontinued about 3 weeks ago. Three months ago cat began to lose weight. During the past 60 days cat has increased thirst and the litter box is wetter than normal. His appetite has increased and he passes large amounts of bulky feces. There is no vomiting, sneezing or coughing. Cat is vaccinated yearly for panleukopenia and upper respiratory viruses and every 3 years for rabies.
	Physical Examination: T. 103 F, HR 180-220, RR 50, and weight is 6 pounds. Cat is restless and uneasy. His coat is dull and ungroomed. Lymph nodes are normal. Thoracic auscultation reveals a definite gallop rhythm. Abdominal palpation reveals mild hepatomegaly and the mammary glands are enlarged and non-painful. Cervical palpation is negative.
	Diagnostic Plan:Using the POVMR format, identify the problems and formulate a diagnostic plan for this case.

2. Problem Identification

A. List the problems you have observed.

No.

Problem

1.

PU/PD

2.

Weight loss with polyphagia

3.

Gallop rhythm/tachycardia

4.

Bulky stools

5.

Hepatomegaly

6.

Mammary gland enlargement

7.

8.

9.

10.

B. Of the problems you have identified, which is (are) the most important to manage?

3. Plan Formulation

A. DX: List ruleouts for the problems you identified in Step 2.

Problem
No.

Ruleout(s)

1.

Diabetes mellitus; Renal failure; Hyperthyroidism

2.

Diabetes mellitus; Hyperthyroidism; Maldigestion

3.

Cardiomyopathy; Dirofilariasis; Thyrotoxicosis

4.

Maldigestion (PEI); Hyperthyroidism; High fiber diet

5.

Hepatic lipidosis; drug induced (megesterol acetate)

6.

Drug induced mammary gland hyperplasia

7.

8.

9.

10.

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

1. 2.

3. 4.

5. 6.

7. 8.

9. 10.

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 15500 x 10³ /mm³ ^Normal normal

RBC 5.8 x 10⁶ /mm³ ^Rouleaux

HGB 12 gr/dl ^Polychrome

PCV 36 % ^Aniso

MCV 42 fl ^Poik

MCV 15 pg ^Crenation

MCHC 32 g/dL ^Target

PLT 350000 x 10³ /mm³ ^Hypochrome

TP 5.4 g/dL ^BasoStrip

FIB mg/dL ^Sphero

Retic 0.2 % ^{NRBC/100
WBC}

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 There is a mild neutrophilia which is likely due to stress. Eosinophilia is present and one should check for parasites. Could be associated with history of miliary dermatitis.

SEG 11000

Band 200

Lymph 3300

Eosin 1000

Mono 0

Baso 0

Other 0

PLTest

Toxic
change 0

Biochemical profile:

Test Value Unit Point your
mouse here
to view Chemistry Norms Test Value Unit

Sodium 148 m mol/L T. Bili 0.2 mg/dl

Potassium 3.5 m mol/L ALKP 150 u/l

Chloride 119 m mol/L ALT 120 u/l

TCO2 16 m mol/L AST u/l

Urea 20 mg/dl LDH u/l

Creatinine 1.1 mg/dl CK u/l

Calcium 10.3 mg/dl GGT 2 u/l

Phosphorus 3.5 mg/dl Magnesium mg/dl

Glucose 115 mg/dl Osmolality mosm/L

T. Protein 6.5 g/dl Anion Gap mosm/L

Albumin 3.1 g/dl

Globulin 3.4 g/dl

A/G ratio

What is your assessment of the biochemical profile ?

Diabetes mellitus is ruled out. Mild to moderate increases in ALKP and ALT. There is no evidence to support cholestasis and primary liver disease is not likely. These enzymes can be increased in cats with hyperthyroidism.

Urinalysis: Microscopic Sediment Exam:

Test Value Unit Test Value Unit

Volume 5 ml WBC 0-2 ml

Color yellow RBC 36162

Transparency clear Bacteria 0

Specific Gravity 1.018 Epitheliel 0

Phosphorus Fat 0

Protein neg mg/dl Sperm 0

Ketones neg mg/dl CaOxalate 0

Bilirubin neg CaCarbonate 0

Blood neg TriplePhos 2 plus

Urobili neg Bilirubin 0 mg/dl

Amorph 0 mg/dl

Casts 0

What is your assessment of the urinalysis data?

The specific gravity is low for a cat. While chronic renal disease might be present, other diseases that interfere with urine concentrating ability should be considered. Hyperthyroidism is one cause on the list of ruleouts.

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

Hyperthyroidism; Dirofilariasis

Have you identified any new problems?
If so, what are they?

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

Total T4; Thoracic radiographs; fecal examinations; occult heartworm test

RX:

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

None is indicated at this time.

Learning Issues:

	Review the causes of PU/PD in cats and describe the mechanisms for hyperthyroidism
	Review the diagnostic procedures for confirming hyperthyroidism in cats
	Describe the sensitivity and specificity of diagnostic tests for feline dirofilariasis
	Review the ECG and radiographic findings of thyrotoxic cardiac disease
	Describe the pathophysiology of thyrotoxic cardiac diseases

No.	Problem
1.	PU/PD
2.	Weight loss with polyphagia
3.	Gallop rhythm/tachycardia
4.	Bulky stools
5.	Hepatomegaly
6.	Mammary gland enlargement
7.
8.
9.
10.

Problem No.	Ruleout(s)
1.	Diabetes mellitus; Renal failure; Hyperthyroidism
2.	Diabetes mellitus; Hyperthyroidism; Maldigestion
3.	Cardiomyopathy; Dirofilariasis; Thyrotoxicosis
4.	Maldigestion (PEI); Hyperthyroidism; High fiber diet
5.	Hepatic lipidosis; drug induced (megesterol acetate)
6.	Drug induced mammary gland hyperplasia
7.
8.
9.
10.

Test	Value	Unit	Point your mouse here to view Hematology Norms	Test	Value
WBC	15500	x 10³ /mm³		^Normal	normal
RBC	5.8	x 10⁶ /mm³		^Rouleaux
HGB	12	gr/dl		^Polychrome
PCV	36	%		^Aniso
MCV	42	fl		^Poik
MCV	15	pg		^Crenation
MCHC	32	g/dL		^Target
PLT	350000	x 10³ /mm³		^Hypochrome
TP	5.4	g/dL		^BasoStrip
FIB		mg/dL		^Sphero
Retic	0.2	%		^{NRBC/100 WBC}
PUNT
AGGR
SED RATE		x 10³ /mm³

Test	%	Absolute	Point your mouse here to view Hematology Norms	There is a mild neutrophilia which is likely due to stress. Eosinophilia is present and one should check for parasites. Could be associated with history of miliary dermatitis.
SEG		11000
Band		200
Lymph		3300
Eosin		1000
Mono		0
Baso		0
Other		0
PLTest
Toxic change	0

Endocrinology Case 3

Expert's Answers

1. Data Base Collection

2. Problem Identification

B. Of the problems you have identified, which is (are) the most important to manage?

3. Plan Formulation

A. DX: List ruleouts for the problems you identified in Step 2.

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

4. Assessment & Follow-up

Analyze the initial database results.

RX:

Learning Issues:

Continue with Expanded Case Evaluation