Test 3: 59 Flashcards
Case 1 – “Spectacular Plan” 12 year old Warmblood mare
You are called to see a horse that has a harsh cough and thick nasal discharge. She is slightly depressed and hasn’t finished her sweet feed this morning. The owner reports that she’s been “not right” for the last 2 days, after returning from her winter completion season in Florida.
Your physical exam reveals the following findings, in addition to the abnormalities described by the barn manager: HR 36bpm, RR 30 bpm, temp 102.5 F. In her thorax, you auscult harsh wheezes dorsally on the right and thick fluid in the trachea. Her GI borborygmi are present in all 4 quadrants, her mucous membranes are pink and moist with a CRT of < 2 secs, and cardiac auscultation reveals no murmurs or arrhythmias. ↑ fibrinogen
i) Write a BRIEF SOAP. In the PE section, make up any results you don’t have, to be as plausible as possible for this case.
ii) In the A section, formulate a rank-ordered problem list, and write your differential diagnoses for the case. For each Ddx, write a brief analytical note about why you think it’s a good Ddx, or factors that make it less likely.
iii) Come up with a diagnostic plan, rank-ordered. For each diagnostic test, briefly state why it would be an appropriate plan.
ase 1 SOAP
Initial history:
age
sex
meds
S:
Spectacular Plan
12 year old warmblood mare
PC= harsh cough, thick nasal discharge
Prog: Not acting right for the past 2 days after returning from a competing in Florida
Meds: none
Systems= anorexia this morning. No V/D/PU/PD
Objective
T= 102.5F, HR=36 bpm, RR 30 bpm
OP: mm pink moist CRT < 2
EENT: thick nasal discharge and harsh cough,
CV: wnl. no murmurs or arrhythmias
RESP: harsh wheezes dorsally on right and thick fluid in trachea
GI/abd: borborygmi present x4
Rectal: not done
UG:
Integ
MS
Neuro: alert
Assessment:
Problem List
1. harsh cough
2. harsh wheezes- lower respiratory disease
3. thick fluid in trachea
4. thick nasal discharge
5. anorexia x 1 day
6. increased rectal temp
7. high fibrinogen
P:
ddx:
* lung disease (viral, bacterial pneumonia- shipping fever, fungal, non infectous)
* guttural pouch disease
* sinuses
Plan
* bloodwork- CBC/ fibringogen
* Xray/ US- cranio ventral portion of caudal lung lobe, right side
* TTA- strep equi zoo- NOT contagious and degenerative neutrophils with intracellular bacteria other infections (ecoli or klebsiella)
Diagnosis
shipping fever- pleuropneumonia
Treatment:
broad spectrum AB (pleural effusion- penicillin, gram -: gent, anaerobic:metro), NSAIDs, chest tap, supportive care- calories
You are called to see a breeding farm that is having problems some young horses in the field where they keep their mares and foals. 7 out of 21 of them have nasal discharge ranging from white to green. 4 of the colts have temperatures ranging from 102.1F to 104.3F. One weanling has a swollen left stifle, and 3 of the sick colts have abnormal lung sounds. One has mild diarrhea. The fibrinogen on the affected foals is 800-1200 mg/dl. The normal foals, most have fibrinogens < 400 mg/dL, but three have levels 500-900 mg/dL.
Write your SOAP on one of the foals with a swollen joint.
write your Ddx list, with an analytical note for each.
What is your diagnostic plan?
DDx
rhodococcus equi
strep equi zoo
ARDS
Plan:
US
rads
TTA- cytology- gram + rods, PCR: Vap A
Treatment:
gram +: macrolides +/- rifampin
You are asked to look at a horse for poor performance; it is a racehorse that “fades” in the second half of a race (starts off running well, but slows down). Your physical examination reveals a horse in good body condition, T 98.8F, P 28 bpm, R 12 bpm, pink MM with a CRT of < 2 seconds. There are good GI borborygmi x 4, the lungs auscult WNL. You note arrhythmia characterized by occasion “skipped beats”, but no murmurs, when you auscult the heart. A lameness exam reveals no gait deficits, the legs palpate within normal limits, with no swelling or heat, and the digital pulses are WNL. A CBC is shown below. The fibrinogen RR is 100-400 mg/dl. fibrinogen 320
i) Write a BRIEF SOAP. In the PE section, make up any results you don’t have, to be as plausible as possible for this case.
ii) In the A section, formulate a rank-ordered problem list, and write your differential diagnoses for the case. For each Ddx, write a brief analytical note about why you think it’s a good Ddx, or factors that make it less likely.
iii) Come up with a diagnostic plan, rank-ordered. For each diagnostic test, briefly state why it would be an appropriate plan.
problem list:
exercise intolerance
arrhythmia
ddx:
upper airway problem- larygneal hemiplasia - no stridor- prob not this, need CK or muscle biopsy
lower airway problem : EIPH (no bleeding, prob not) , mild asthma (need further testing)
heart problems: afib, 2nd degree AV block (EKG)
lameness- (need high speed treadmill workup)
Plan
asthma: pulmonary function test, BAL
EIPH: endoscopy
Afib: EKG
25 year old Arab mare. Presents in severe respiratory distress that owners say has been worsening over the last month. PE: T 104.1 F, P 60 bpm, R 60 bpm. MM pale, bluish, CRT 3 s. Cardiac auscultation NSF, extensive crackles, fine and soft, throughout lung fields. Body condition score 3/9, GI borborygmi present x4, normal integument, musculoskeletal exam. The intern has already pulled an arterial blood gas and done radiographs (you’ll talk to her later about working through a case methodically!)
write your Ddx list, with an analytical note for each.
What is your diagnostic plan?
problem list:
crackles- lower airway disease: hypoxia (cyanotic), diffuse and nodular alveolar pattern xray
high temp
low BCS
ddx:
EMPF- multinodular pulmonary fibrosis
bacterial pneumonia (xrays do not show ventral disease- xrays have nodular disease everywhere, so prob not bacterial)
fungal pneumonia (cause nodules on xray, primary or secondary)
cancer
plan:
EMPF: BAL EHV5 PCR +
fungal: cytology or PCR
Beulah is a 3 year old grade mare that was “rescued” from a horse sale 2 weeks ago. She developed a high fever (104.5 F) and thick, purulent nasal discharge one week ago, and now three other horses in the barn have nasal discharge and fever. Her submandibular lymph nodes are enlarged and hot. ↑↑ fibrinogen
write your Ddx list, with an analytical note for each.
What is your diagnostic plan?
problem list
nasal discharge
enlarged lymphnodes
high temp
multiple animals
ddx
strangles- lymphnodes (99% of cases)
flu
tooth root abcess
foreign body
plan:
nasal swab to rule out flu
stangles: drain abcess/ lymphnodes- PCR- strep equi ssp equi- very contagious- isolate until PCR negative:
Treatment
mild- supportive care and drain. severe- resp distress- trach, drain abscess, AB- penicillin (for strep)
You are called to see a horse that has a harsh cough and thick nasal discharge. She bright and alert, eating well. She is kept in a barn at night, and the owner doesn’t ever let her get cold during this nasty winter. The doors and windows are kept tightly closed so the water buckets don’t freeze overnight. She is turned out during the day into a field with 4 other horses, and eats from a round bale. All of the other horses are fine.
Your physical exam reveals the following findings, in addition to the abnormalities described by the barn manager: HR 36bpm, RR 30 bpm, temp 99.5 F. In her thorax, you auscult harsh wheezes dorsally on the right and thick fluid in the trachea. Her GI borborygmi are present in all 4 quadrants, her mucous membranes are pink and moist with a CRT of < 2 secs, and cardiac auscultation reveals no murmurs or arrhythmias.
A CBC and fibrinogen show the following (the fibrinogen RR is 100-400 mg/dl.): fibrinogen 295
write your Ddx list, with an analytical note for each.
What is your diagnostic plan?
problem list
wheezes
elevated resp
cough
nasal discharge- thick fluid in trachea
no fever
DDX
lower airway disease: severe asthma (poor ventilation, wheezes, no fever)
pneumonia- (nasal discharge, abnormal lung sounds, but no fever or inflammation on bloodwork)
upper airway disease: flu
Plan:
asthma: BAL (>25% neut) and pulmonary function test
if +: reduce dust, steroids, bronchodilators
“Sheza Doozy” – 2 year-old Quarterhorse mare
Doozy returned from the Quarter Horse World Congress Show one week ago. She had a temperature of 103.5F coming off the trailer, and so her owner thought she probably had shipping fever, so started her on SMZ antibiotics without a veterinary exam. The antibiotics worked great, and within 3 days she was back to normal. But now several other horses in the barn have a fever of 103-104.9F. They have a harsh, dry cough, serous nasal discharge and decreased appetite.
What other history questions do have?
write your Ddx list, with an analytical note for each.
What is your diagnostic plan?
vaccine history?
ddx:
viral- flu or equine herpes
bacteria pneumonia (recent travel history-shipping fever, but other horses caught it and shipping fever caused by strep equi zoo is not contagious)
strangles- (contagious, young animals, recent travel, No swollen lymphnodes)
plan:
viral: PCR- rest and support (NO antibiotics)
What is the difference between mild and severe asthma?
mild normal physical exam at rest
severe: symptoms/episodes at rest
How do you diagnose asthma in horses?
BAL
* mild: >5% neuts, >0.5% eos, >2% mast cells
* severe: >25% neutrophils
pulmonary function test
What are some non-medication treatments for asthma?
How do you treat asthma medically?
put outside, no straw, improve ventilation
steroids, bronchodilators
How long do you treat asthma for?
life long
do not use bronchodilators long term can cause B2 receptors to move into cells
controllable but not curable
What sort of horses get EIPH?
What is necessary in order for a horse to “bleed”?
racehorses
speed
How do you diagnose EIPH?
endoscopy
BAL
radiographs with opacity in caudodorsal location
How do you prevent EIPH?
dont run fast
lasix- reduce PA pressure
Why is EIPH a problem?
can lead to secondary infections
