Signalment: Canine, English pointer, F/S, 6 years old
	History: Dog had pruritic dermatitis and was treated every 2 months for 5 treatments with methyl prednisolone acetate IM. During this time, dog experienced one episode of shaking and anorexia. Treated at that time for "kidney infection" despite having a normal UA. 30 days after last steroid injection, dog developed vaginal discharge 2 weeks post estrus. One month later, dog was listless, nervous, weak in the pelvic limbs, spordic vomiting and wouldn't jump or play. TPR normal. Inflammed vulva, and dark black stools were found. PCV 51 and WBC 9,000. 2 weeks later, exploratory laporatory for pyometra. Uterus normal. OHE performed. Did poorly under anesthesia but responded to fluids and dexamethasone. 10 days post surgery, dog developed depression, anorexia, sporadic vomiting, weight loss, hemorrhagic diarrhea. Dog referred for diagnosis and treatment.
	Physical Examination: T: 101.7F; HR 155; RR: panting, Wt: 31 pounds; MM pale and dry; CRT >3.0 secs. Dog is thin, depressed, weak, and dehydrated (5%). Pulse is weak, no pulse deficits noted. Rectal exam reveals dark tarry feces. Neurological examination is normal except for generalized weakness. Well healed abdominal incision. Auscultation and abdominal palpation are negative. Lymph nodes are normal.
	Diagnostic Plan:Using the POVMR format, identify the problems and formulate a diagnostic plan for this case.

No.	Problem
1.	Generalized weakness, depression, anorexia, and sporadic vomiting
2.	Pale mucus membranes
3.	Dark tarry stools
4.	Dehydration
5.
6.
7.
8.
9.
10.

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

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

Problem No.	Ruleout(s)
1.	Metabolic diseases: hypoadrenocorticism, renal failure, liver failure, hypoglycemia, hypercalcemia; Myopathy; Motor end plate disease; Neoplasia (lymphosarcoma)
2.	Anemia; hypotension
3.	Upper GI hemorrhage: Ulceration, neoplasia, endoparasites, coagulopathy, hypoadrenocorticism
4.	See ruleouts for problems 1 and 3
5.
6.
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.

Analyze the initial database results.

Hematology:

RBC Morphology:

Test	Value	Unit	Point your mouse here to view Hematology Norms	Test	Value
WBC	13100	x 103 /mm3		Normal
RBC	4.8	x 106 /mm3		Rouleaux
HGB	12.5	gr/dl		Polychrome	Plus 1
PCV	28	%		Aniso	Plus 1
MCV	70	fl		Poik
MCV	22	pg		Crenation
MCHC	31	g/dL		Target
PLT	250000	x 103 /mm3		Hypochrome	Plus 1
TP	6.2	g/dL		BasoStrip	none
FIB		mg/dL		Sphero	none
Retic	0	%		NRBC/100 WBC	Est. at 1-2
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	A moderate non-regenerative anemia is present despite evidence dog may be bleeding into GI tract. Lymphopenia and eosinopenia are present (stress, previous steroid therapy?) Since dog is dehydrated, PCV and plasma proteins may be falsely increased. Thrombocytopenia as a cause for coagulopathy has been ruled out.
SEG	11528
Band	262
Lymph	589
Eosin	66
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	138	m mol/L		T. Bili	0.1	mg/dl
Potassium	4.5	m mol/L		ALKP	404	u/l
Chloride	111	m mol/L		ALT	270	u/l
TCO2	14	m mol/L		AST		u/l
Urea	18	mg/dl		LDH		u/l
Creatinine	1	mg/dl		CK		u/l
Calcium	9.3	mg/dl		GGT		u/l
Phosphorus	3.5	mg/dl		Magnesium		mg/dl
Glucose	138	mg/dl		Osmolality		mosm/L
T. Protein	6.1	g/dl		Anion Gap		mosm/L
Albumin	3.5	g/dl
Globulin	2.6	g/dl
A/G ratio

What is your assessment of the biochemical profile ?

Sodium and chloride are low end of normal, potassium and calcium are normal. The increased ALKP might be caused by previous glucocorticoid therapy. The increased ALT is more difficult to explain. While occasionly seen with steroid therapy, we should consider other mechanisms such as hypoxia or concurrent liver disease. Hypoglycemia is ruled out and dog is not azotemic as would be expected in renal failure associated with these clinical signs. Hypercalcemia is ruled out.

Urinalysis:

Microscopic Sediment Exam:

Test	Value	Unit		Test	Value	Unit
Volume	5	ml		WBC	0-2	ml
Color	pale yellow			RBC	0-2
Transparency	clear			Bacteria	0
Specific Gravity	1.011			Epitheliel	0
Phosphorus				Fat	0
Protein	neg	mg/dl		Sperm	0
Ketones	neg	mg/dl		CaOxalate	0
Bilirubin	neg			CaCarbonate	0
Blood	trace			TriplePhos	0
Urobili	neg			Bilirubin	0	mg/dl
				Amorph	0	mg/dl
				Casts	0

What is your assessment of the urinalysis data?

The dog is not concentrating urine in the face of dehydration. The results might suggest renal failure but affects of previous therapy should be considered as well.

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

Hypoadrenocorticism (iatrogenic or atypical addison's disease)

Have you identified any new problems?	No Yes	If so, what are they?
Non-regerative anemia and possible hepatopathy

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

ACTH Stimulation test, clotting profile

RX:

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

Balanced electrolyte solution for dehydration; gastrointestinal protectants????

Learning Issues:

	Describe the causes of upper GI hemorrhage in dogs
	Describe the pathophysiology of iatrogenic hypoadrenocorticism
	Review the clinical signs and laboratory findings in dogs with atypical hypoadrenocorticism

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