Case 9 Endocrinology Answers

Endocrinology Case 9

Expert's Answers

1. Data Base Collection

	Signalment: Labrador retriever, 10 years old, M/C
	History: Episodes of weakness, pelvic limb ataxia, and lethargy of 4 months duration are reported by the owner. The episodes rarely occur at rest and are most common and severe following exercise or 8-10 hours after eating. Appetite is good and urination and defecation are normal. There is no coughing, sneezing, or PU/PD. The dog eats premium brand dry food and is fed once a day. He is vaccinated every year but is not on heartworm preventative. Seizures have not been noted.
	Physical Examination: T. 101.8 F; RR 25; HR 96; MM are pink and CRT <3.0 seconds. Dog is alert, responsive and in good flesh. A grade II/IV holsystolic heart murmr is present over the mitral area. The pulse and lungs are normal. Abdominal palpation is negative. Lymph nodes are normal. Neurological examination is normal.
	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.

Episodic weakness with ataxia

2.

Holosystolic heart murmur

3.

4.

5.

6.

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.

Metabolic/endocrine: hypoglycemia, hypercalcemia, hyper- and hypokalemia; Cardiovascular disease: dirofilariasis, heart failure, cardiac arrythymia; Neuromuscular endplate disorder: myasthenia gravis; Myopathy

2.

Mitral valve insufficiency (endocardiosis, valvular endocarditis, cardiomyopthy)

3.

4.

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.

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 13500 x 10³ /mm³ ^Normal

RBC 6.8 x 10⁶ /mm³ ^Rouleaux none

HGB 18 gr/dl ^Polychrome none

PCV 45 % ^Aniso none

MCV 65 fl ^Poik none

MCV 24 pg ^Crenation none

MCHC 34 g/dL ^Target none

PLT 285000 x 10³ /mm³ ^Hypochrome none

TP 7 g/dL ^BasoStrip none

FIB 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 An eosinophilia is present. Check carefully for parasites including occult heartworm test. Normal or increased eosinophils and lymphocytes in a stressed dog can indicate cortisol deficiency. There is no evidence of sepsis.

SEG 7000

Band 0

Lymph 3000

Eosin 2500

Mono 1000

Baso 0

Other

PLTest

Toxic
change

Biochemical profile:

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

Sodium 145 m mol/L T. Bili 0.2 mg/dl

Potassium 4.5 m mol/L ALKP 65 u/l

Chloride 118 m mol/L ALT 30 u/l

TCO2 16 m mol/L AST u/l

Urea 9 mg/dl LDH u/l

Creatinine 1.1 mg/dl CK u/l

Calcium 10.5 mg/dl GGT u/l

Phosphorus 4 mg/dl Magnesium mg/dl

Glucose 65 mg/dl Osmolality mosm/L

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

Albumin 3 g/dl

Globulin 3.5 g/dl

A/G ratio

What is your assessment of the biochemical profile ?

The blood glucose is slightly below normal and should be carefully rechecked. Disorders of potassium and calcium metabolism are ruled out. There is no evidence of liver failure.

Urinalysis: Microscopic Sediment Exam:

Test Value Unit Test Value Unit

Volume VOIDED: 10 ml WBC 40-60 ml

Color Dark yellow RBC 0-3

Transparency cloudy Bacteria Plus 2

Specific Gravity 1.045 Epitheliel few

Phosphorus Fat 0

Protein Plus 2 mg/dl Sperm 0

Ketones 0 mg/dl CaOxalate 0

Bilirubin trace CaCarbonate 0

Blood 0 TriplePhos few

Urobili trace Bilirubin 0 mg/dl

Amorph Plus 3 mg/dl

Casts o

What is your assessment of the urinalysis data?

Dog concentrates well. Numerous WBCs and protein present but sample was voided and potentially contaminated. Do cystocentesis and repeat UA.

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

Hypoglycemia: need to pursue these causes: Beta-cell neoplasia, non-pancreatic tumors, and cortisol deficiency. Sepsis, uremia and liver failure are ruled out.

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

Yes: mild hypoglycemia, possible pyuria, eosinophilia

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

Cystocentesis UA, Occult heartworm test, controlled fast and repeat glucose every 2-3 hours. If hypoglycemia is confirmed, perform ACTH stimualtion test to rule out hypoadrenocorticism and insulin:glucose pairs to rule out insulinoma.

RX:

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

None

Learning Issues:

	Review the pathogenesis of the clinical signs associated with hypoglycemia.
	Describe the causes of hypoglycemia in dogs.
	Review the signalment of dogs affected with beta cell neoplasia.
	Describe other species predisposed to beta cell neoplasia.

No.	Problem
1.	Episodic weakness with ataxia
2.	Holosystolic heart murmur
3.
4.
5.
6.
7.
8.
9.
10.

Problem No.	Ruleout(s)
1.	Metabolic/endocrine: hypoglycemia, hypercalcemia, hyper- and hypokalemia; Cardiovascular disease: dirofilariasis, heart failure, cardiac arrythymia; Neuromuscular endplate disorder: myasthenia gravis; Myopathy
2.	Mitral valve insufficiency (endocardiosis, valvular endocarditis, cardiomyopthy)
3.
4.
5.
6.
7.
8.
9.
10.

Test	Value	Unit	Point your mouse here to view Hematology Norms	Test	Value
WBC	13500	x 10³ /mm³		^Normal
RBC	6.8	x 10⁶ /mm³		^Rouleaux	none
HGB	18	gr/dl		^Polychrome	none
PCV	45	%		^Aniso	none
MCV	65	fl		^Poik	none
MCV	24	pg		^Crenation	none
MCHC	34	g/dL		^Target	none
PLT	285000	x 10³ /mm³		^Hypochrome	none
TP	7	g/dL		^BasoStrip	none
FIB		mg/dL		^Sphero	none
Retic	0	%		^{NRBC/100 WBC}	none
PUNT
AGGR
SED RATE		x 10³ /mm³

Test	%	Absolute	Point your mouse here to view Hematology Norms	An eosinophilia is present. Check carefully for parasites including occult heartworm test. Normal or increased eosinophils and lymphocytes in a stressed dog can indicate cortisol deficiency. There is no evidence of sepsis.
SEG		7000
Band		0
Lymph		3000
Eosin		2500
Mono		1000
Baso		0
Other
PLTest
Toxic change

Have you identified any new problems?		If so, what are they?
Yes: mild hypoglycemia, possible pyuria, eosinophilia

Endocrinology Case 9

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