What Is Wrong With These Patients? Flashcards
Why are we so worried?
- The owners arrive with Billy just as you arrive at work
- They are worried he is very sleepy this morning and think it’s because they haven’t managed to give him the Prokolin
- He hasn’t eaten since yesterday afternoon when he had a couple of teaspoons of fish
- This morning there was a lot of very smelly dark red/brown diarrhoea in his puppy crate and he had vomit on his legs and chest
- They have him wrapped up in a blanket and would like to see someone
- Your colleague is away today (Christmas shopping)
- he seems to have profuse haemorrhagic diarrhoea
- he is still vomiting
- he is young and therefore likely to be immune compromised
- we have no proof he is vaccinated or wormed
- he has not eaten enough in the last 2 days
- he has deteriorated and is “sleepy”- what might this mean?
Billy’s owners are upset and blaming themselves
What should we do?
- The owners arrive with Billy just as you arrive at work
- They are worried he is very sleepy this morning and think it’s because they haven’t managed to give him the Prokolin
- He hasn’t eaten since yesterday afternoon when he had a couple of teaspoons of fish
- This morning there was a lot of very smelly dark red/brown diarrhoea in his puppy crate and he had vomit on his legs and chest
- They have him wrapped up in a blanket and would like to see someone
- Your colleague is away today (Christmas shopping)
- arrange to take Billy through to examine him
- see if a member of staff can offer the owners a cup of tea (or coffee, but nothing stronger!)
- ask if someone can find out if details of Billy’s vaccinations and worming have arrived yet
- suggest they wash/disinfect their hands
Billy’s is young and at risk of an infectio, but might have a serious infection what should we do?
- The owners arrive with Billy just as you arrive at work
- They are worried he is very sleepy this morning and think it’s because they haven’t managed to give him the Prokolin
- He hasn’t eaten since yesterday afternoon when he had a couple of teaspoons of fish
- This morning there was a lot of very smelly dark red/brown diarrhoea in his puppy crate and he had vomit on his legs and chest
- They have him wrapped up in a blanket and would like to see someone
- Your colleague is away today (Christmas shopping)
- avoid direct contact between Billy or his owners and any other dogs in the waiting room
- minimise the risk of Billy contaminating the practice
- protect Billy from any additional risk of infection
How worried are we?
What is the problem list?
Very worried!
- hypothermia
- tachycardia and poor pulse quality
- pale mucous membranes
- haemorrhagic diarrhoea
- vomiting
- anorexia
What does the abscence of a dorsal metatarsal pulse suggest?
Hypotension - critical
What are the top 3 differentials?
- parvovirus
- bacterial infection eg Salmonella, E Coli
- parasitic infection/giardia
- intussusception (but no palpable mass)
- idiopathic haemorrhagic gastroenteritis (very unlikely in a young puppy- quite likely in older vaccinated dogs)
What is our action plan?
- Place an iv line and collect a small amount of blood for the following:
- PCV/TS and blood smear
- why is a blood smear so important in this case?
- Blood glucose
- Electrolytes if possible: Na/K
- Urea/creatinine
- PCV/TS and blood smear
- Do we need to warm Billy up and if so how should we do this?
What fluid therapy could we give Billy?
What do we not give?
- isotonic crystalloid fluid (Hartmanns) as a bolus ie 10-20mls/kg over 15 minutes which could be repeated up to 3 times depending on his response (T/P/R, pulse quality, demeanour)
- colloid (eg Voluven) at 5mls/kg over 15 minutes and repeat if no response
DO NOT GIVE HYPERTONIC SALINE
What additional questions should we ask the owners?
Angela DSH 6yoFN
- what does Angela bring up and has this changed since she has been vomiting more frequently?
- what do you feed her and have you tried any different diets over the years or recently?
- is she a hunter and if so does she eat what she catches?
- what colour stools is she passing?- any fresh blood or mucus?- any straining when you see her in the litter tray?
- how would you score Angela’s stools:
https://www.waltham.com/dyn/_assets/_pdfs/resources/FaecesQuality2.pdf
- do the vomiting days coincide with the soft stool days?
- does she seem less keen to eat on the vomiting days?
- is she still going out just as much as she used to?
- is she happy to jump on to furniture, stretch out, showing normal behaviour?
How worried are you about angela?
The scenario you have shouldn’t concern you too much in that Angela is not dehydrated and seems very stable.
BUT- something has changed and while vomiting once a month is not a big deal for many cats and their owners- the change in clinical signs is worrying.
With added history we now genuinely do have more concerns.
What is angelas problem list?
- weight loss
- it would be useful to have a BCS as well as weight for this cat (BCS 3/9)
- change in frequency of vomiting
- new GI signs (intermittent SI diarrhoea)
- variable appetite
- abdominal pain?
- change in behaviour (staying in, quieter/antisocial, change in posture) is concerning
What are the main differentials for her weight loss? (6)
- Inadequate food intake
- associated with ↓ appetite (ie 2ry to other disease)
- inability to eat (no dysphagia reported)
- ↑ requirements (if anything she should need less food as she is quieter, not going out)
- Maldigestion/malabsorption
- GI disease (a range of options….!)
- Endocrine disease (usually older cats?)
- hyperthyroid
- diabetes (no history of PU/PD)
- Renal disease
- Neoplastic disease
- examples include GI lymphoma
- Cardiac disease (no supporting findings on physical exam)
What are the main differentials for vomiting and diarrhoea?
- Could she have infectious disease? Probably not because
- single cat house
- several weeks duration superimposed on a low grade lifelong history of vomiting
- but could it be FeLV/FIV related? or antibiotic responsive diarrhoea?
- Could she have inflammatory disease?
- food intolerance/food allergy
- inflammatory bowel disease
- pancreatitis
- inflammatory liver disease
- what types of liver disease can cats get?
- Could she have neoplastic disease?
- lymphoma?
- Could she have endocrine disease?
- hyperthyroid (is she too young?)
- hypoadrenocorticism (very rare in cats)
- Could she have partial intestinal obstruction?
- slow moving foreign body
- intussusception
- progressive intestinal mass = narrowing intestinal lumen
What would be a justification for haematology?
to see if there is any suggestion of systemic inflammation or unexpected neutropenia (might indicate increased susceptibility to infection?), any indication of significant chronic disease (anaemia?). This would not be a reason to do haematology but sometimes we find changes that suggest we should check clinical parameters again eg high PCV could suggest dehydration.
What would the justification be for biochemistry?
to look for causes and consequences of her recent progressive vomiting and diarrhoea, to help rule in or out underlying disease including hepatic disease, renal disease, endocrine disease, to look for evidence of inflammatory markers
What diagnostic tests could we do?
- Haematology
- Biochemistry
- Urinalysis
- FeLV/FIV
- TLI
- fPLI
- Folate
- Cobalamin
- Faecal analysis
- Abdominal radiography
- Abdominal ultrasound
What is the justification for abdo radiography?
look at organ size, shape and position, to look for any evidence of intestinal obstruction
What can be seen?
Heterogeneous pancreas, dilated pancreatic duct
What can be seen?
Mild thickening of the muscularis layer of the SI
