Formative clinical reasoning

Question 1

Benjy is a 5 year old male neutered domestic shorthaired cat. He lives in a fifth floor flat and is a 100% indoor cat and has always used a litter tray. He eats both wet and dry food. His owner, Miss Fitzgerald, is currently on holiday so the cat sitter who goes and feeds him twice a day has brought him to the surgery.

She has noticed that he keeps going to his litter tray to urinate (4 times in the 1/2 hour she was there this morning) and there is blood in his urine.

You check the computer records and discover this has happened twice before. The last time was when Miss Fitzgerald was away over Christmas.

The cat sitter has brought a urine sample with her, as she collected some Mikki litter from the surgery last night.

Physical Examination

On presentation Benjy is bright, alert and responsive. He weighs 5.5kg and has a body condition score of 4/5. He has a small area of alopecia on his ventral abdomen. A complete examination is otherwise unremarkable.

Having studied the presenting case history, physical examination findings and the urine sample, consruct a list of problems which need investingating in order to reach a diagnosis in this case?

Answer 1

1. History of pollakiuria/dysuria
2. Overweight
3. Alopecia
4. Red discolouration of the urine/haematuria/haemoglobinuria/red water

Question 2

Construct a list of four most likely differential diagnoses for Benjy.

Answer 2

1. Idiopathic FLUTD*
2. Urolithiasis
3. Urinary tract infection
4. Behavioural problem

Question 3

List 4 tests you would perform on the urine sample.

Answer 3

1. Dipstick: blood, protein, pH
2. USG using refractomer
3. Sediment examination
4. Culture
5. Protein:creatinine ratio

Question 4

Benjy’s urine sample results are below and are accompanied by a basic blood screen you have run given this is the third time Benjy has had an episode like this.

Interpret these diagnostic findlings and comment on any results which lie outside of the normal range.

Answer 4

• Award 2 marks in total for blood,
• 1 mark for stating ‘normal’
• 1 mark for stating slightly increased urea and PCV is likely due to mild dehydration. (USG fits this scenario)
• 1 mark for stating significant haematuria,
• 1 for stating proteinuria on dipstick: unlikely renal/glomerular disease as urea/crea normal,
• 1 mark for commenting that urine P:CR shows proteinuria to be insignificant,
• 1 mark for suggesting that origin of proteinuria is likely lower urinary tract

Question 5

Subsequent imaging studies are unremarkable. Given the diagnostic findings thus far, you suspect idiopathic FLUTD. How would you manage Benjy over the next few days?

Answer 5

1. Analgesia/anti-inflammatories (1 mark)
2. Increased water intake/change to wet diet (1/2 mark each)
3. Environment changes: increase litter trays, increase activity (1/2 mark)
4. Ancillary drugs: possibly GAG supplements, pheromones (1/2 mark)

Question 6

What would you discuss with the owner about his long term management and prognosis?

Answer 6

1. Likely to recur
2. Weight loss/exercise
3. Stress management/dietary management/environment management
4. Warn of risk of obstruction