Going through

a bit of a very rough patch here. The last weekend at work was very hard. It culminated in an exhausting (mentally, physically, and emotionally) surgical ordeal. I was thoroughly looking forward to the 9 days away from work, relaxing, spending time with my family, and recharging. Yesterday, at my uncle's cabin in the woods, we weathered a terrible windstorm. My husband's car - which we have owned for 3 months, have not paid off fully, and on which we do not carry comprehensive insurance - was crushed by a tree. It's the first car we've ever NOT bought in cash, it's the nicest car he's ever had, and it was a good deal through a friend. Now, we owe $5500 on a car that is totaled. I've been reminded to put this in perspective, but at the moment, as we're struggling to get started with savings and with my student loans coming due next month, this couldn't come at a worse, more stressful time. I am grateful no one was hurt, and my uncle's house made it through the storm unscathed, but I feel sick to my stomach all the same.

Look people, I don't care WHAT you do in your spare time...

I was sleeping quite soundly at work the other night. We've been DEAD DEAD DEAD. Dead as in NO patients in the hospital, for the last few nights, so I've been able to sleep. At 6:30am, a knock came on the door as my technician alerted me that we had a patient.

Said patient was a 2 year old dachshund. The owner thought she was having back trouble - which is a common condition in long-backed dogs.

When I first saw her, a back condition was not my biggest concern. She was exhibiting multi-focal neurological signs. This means that she had signs that pointed to different areas of the nervous system. She was ataxic (swaying when she walked), disoriented, knuckling in all 4 feet, her head was tremoring/bobbing, and she had very dilated pupils. Her temperature was 103.8.

I went to talk with her owner, a young, tattoed guy. I asked the standard questions: onset of signs, first thing you noticed, appetite, urination, defecation, other pets in the house, anything she could have gotten into, any medications in the house? His history didn't give me any clues, so back I went to stare at my patient. She looked very very sick. I pondered diffentials for multi-focal neuro disease - encephalitis? necrotizing meningoencephalitis? granulomatous meningoencephalitis? As I pondered, I idly repeated my physical exam to see if I'd missed anything. When I rolled up her eyelid, I was AMAZED at how red both of her eyes were...red like a person who had just smoked a big fat joint...

Back I went to the owner. "Do you or your wife smoke pot?" I asked in an innocent voice. The guy looked at me, smiled sheepishly, and gave me a thumbs up.

The urine drug test was positive for THC. Only after that did the owner tell me that his wife found a bud on the floor...

A bolus of fluids later, a heavy sedative, and our patient was rolling over on her back with all four legs in the air, finally able to relax. We were tempted to prop a bag of Doritos up next to her to complete the picture, but we didn't (this time).

Look folks, I don't care in the slightest if you smoke pot. A great majority of the world does. If you smoke pot, and your dog starts acting "oddly" at 6:30 in the morning, and you bring her to the ER - just save me the time, hysterics, and your money when I'm running bloodwork, and TELL ME. That way, I can give your dog a bag of Doritos and call it a night instead of going into mental hysterics over encephalitis.

Thanks!

What I did...

This is the final installment in my case study (see posts below).

In the end, I rehydrated the patient for 6 hours. He continued to be lethargic and depressed. I made the decision to go to surgery and see what we were facing.

When I opened him up, I found a massive liver tumor, as I suspected. It had not yet ruptured (as evidenced by the lack of fluid in the abdomen on ultrasound), but it was only days away from doing so. There were enormous pockets of necrosis and abscessation. As I was slowly and meticulously dissecting it away from the diaphragm (it had formed adhesions to the body wall and the diaphragm), I punctured the mass, and blood poured into the abdomen. I clamped it off and gave it time to clot, then continued working. During the surgery, my patient's blood pressure fell and fell and fell till it was in the basement. He received crystalloid boluses (NormR) followed by Hetastarch (colloid), and then a whole blood transfusion when his PCV was 14%. He also received dopamine intra-operatively to help keep his BP up.

An hour and 15 minutes later, the whole left side of the liver was out. The tumor enveloped all the lobes on the left side, and I had to remove it all. Everything else looked good, so I checked for bleeding, found none, lavaged the abdomen, and closed him up. There was no evidence of metastasis anywhere. Even the spleen looked happy.

We are 48 hours out from surgery, and he is slowly recovering. His kidney values are falling, but not as much as I would like. He is still nauseated and isn't able to eat. He is - however - able to move around his cage and go outside. His PCV is holding at around 24%.

The tumor will be sent for histopathology. In all likelihood, it will be read as a hepatocellular carcinoma - the most common malignant hepatic tumor of dogs. These are slow growing tumors that rarely metastasize and have a GREAT prognosis if not diffuse or metastatic (as this dog's wasn't). Prognosis is 4 years, and usually, the patient dies of something else unrelated to the cancer.

I am left with more questions than answers. I will never know if I did the right thing by going to immediate surgery. Should I have waited, fully rehydrated him, seen if he would stabilize more then taken him to surgery? Surgery was absolutely indicated for this little guy, otherwise, the tumor would have ruptured at some point in the near future causing a hemoabdomen. I know that. I just don't know if it should have been done that night, or if I should have treated his renal dysfunction for a week or more, than taken the tumor out.

Any thoughts?

It's that time of year.

In 2 ER shifts (roughly 24h total), I euthanized 10 animals - everything from the laterally recumbent, anemic, hypothermic, flea covered 2 month old kitten drop-off to the 14 year old, dearly loved family dog that is acutely down in the rear. I'm feeling kind of numb right now and very bummed. It's funny how that kind of stress manifests itself after the fact. I wasn't crying or upset during any of the euthanasias, but here I am...sitting here, questioning everything I do, and feeling very insecure about myself.

Time to make cheesecake.

The complexities and conundrums of medicine...

So, a little case study for my pre-vet, veterinary student, and vet readers:

My technician brings in her 12 year old, 4 kilogram, male castrated Yorkie. Two days ago, he was normal, bright, and healthy. At that time, he became slightly lethargic. It progressed to vomiting and severe depression. He has no known history of medical problems (she has owned him for 2 years, and he was a rescue), does not receive any medications other than cyclosporine (Optimmune) for his dry eye (keratoconjunctivitis sicca/KCS). He is an indoor dog, up to date on his vaccines except for leptospirosis, and he didn't ingest anything he shouldn't have. He goes outside on walks with the owner and her daughter and sometimes plays in a dirty, algae-filled pond near the house.

My physical exam findings were as follows:

1) A very depressed dog
2) 10% dehydration (eyes sunken in, skin stays tented when pinched, gums dry, capillary refill time greater than 3.5 seconds)
3) A painful, doughy feeling abdomen
4) Sparse hair growth/alopecia over the middle of his back to his tail, fleas
5) Mucopurulent eye discharge OU consistent with history of KCS
6) Very slightly icteric (yellow), very pale gums

I started with bloodwork and urine specific gravity and found the following abnormalities:

PCV/TS 30/10.5

White blood cell count of 66,000 (normal 5,000-12,000)
Blood smear confirms that this is a neutrophilic leukocytosis with a significant left shift (14% bands noted)

Blood urea nitrogen (BUN) 188 (normal 7-20)
Creatinine 6.4 (normal 0.2-1.4)
Phosphorous 20.2 (normal 2-4)

ALT 1000 (normal 20-200)
ALP 550 (normal 50-220)
GGT 35 (normal 0-7)

Bilirubin 2.0 (normal 0.2-0.7)

Cholesterol 427 (normal 50-300)

prothrombin time (PT): 10 sec (normal 3-17)

activated partial thromboplastin time (aPTT): 110 sec (normal 74-103)

Urine specific gravity: 1015 (AFTER a bolus of 100mL NormR)

Systolic BP: 70

A slide agglutination test was negative for macro or micro agglutination. No agglutination was noted in the blood tube. No spherocytes were seen on smear. Very mild anisocytosis was noted. No polychromasia was seen.

What problems do we have? What differentials would be appropriate for this dog? What diagnostics would you have done next? What treatments would you institute? What other information could be useful?

Case study continued

To approach this as I was taught in vet school, I would begin with a problem list based on my physical exam:

1) Vomiting
2) Depression
3) Severe dehydration
4) Icterus/jaundice
5) Hair loss
6) Painful abdomen
7) Pale gums

From there, I would formulate a differential list. Now, I was taught to formulate differentials for EVERY problem...but in the real world, that is rarely practical. The differentials for vomiting alone could take up 4 pages. So, I would approach this globally - look at all of my problems and then formulate a differential list.

So, my differentials for this patient based on his problems (not on his bloodwork yet):

1) Liver disease (jaundice!) - cancer would be #1, as he is 12 years old
2) Leptospirosis - a bacterial disease that can cause liver and kidney disease would be a very close #2...maybe tied for #1
3) Acute liver failure with severe dehydration and possible renal insufficiency
4) Hemolytic anemia - based on the presence of jaundice, dehydration, pale gums, and depression
5) Bile duct obstruction/rupture
6) Ingestion of toxin
7) Hypothyroidism/myxedma coma

Those were my major differentials for this case. Then I turned to my bloodwork...(to be cont'd)

Case study part 3

What did my bloodwork tell me?

1) Significant dehydration and significant anemia -a PCV of 30 with a TS of 10.5 should tell you that this patient is SEVERELY dehydrated. A normal TS is about 5.5-7.5. A normal PCV should be between 35-45. This patient has a very high TS with a normal to low normal PCV. That tells you 2 important things - the patient is severely dehydrated (TS 10.5), and the patient is VERY anemic (PCV of 30 in severe dehydration which means it's probably around 18-20 when rehydrated).

2) Severe azotemia (elevation in kidney enzymes) with a relatively dilute urine -likely representing both pre-renal and renal azotemia - urine specific gravity 1015 (although NOT isosthenuric, as one would expect in acute kidney failure AND this was after a bolus of fluids. On the other hand, this is still not appropriately high for a dog that is 10% dehydrated).

3) Significantly elevated liver enzymes - ALT 5x normal, ALP 2.5x normal, GGT 5x normal.

4) An elevated bilirubin (but not enormously).

5) Significant inflammation and/or infection is present due to a VERY elevated WBC (66,000) and the presence of 14% bands on a blood smear (a left shift indicating that the bone marrow is experiencing overwhelming demand for neutrophils and cannot keep pace with production).

6) Low systolic blood pressure (hypotension) - normal should be around 90-100.

7) Mild to moderate hypercholesterolemia

8) A very mildly increased clotting time (aPTT)

Case study part 4

Revised differential list based on findings:

1) Leptospirosis
2) Primary hepatic or renal cancer, metastatic cancer
3) Acute renal failure overlying a liver problem such as hepatitis or cancer

Hemolytic anemia is still a possibility although it is lower on the list due to the lack of agglutination noted, the lack of spherocytes, no polychromasia, and mild anisocytosis (no evidence of regeneration or ongoing hemolysis).

My plan then was as follows:

1) Correct dehydration over 6 hours with aggressive fluids: calculated deficit of a 4kg dog at 10% = 400mL. Initially bolused 250mL of NormR leaving a deficit of 150mL to correct over 6 hours = 25mL/h + maintenance at 1mL/lb/h (4mL) + ongoing losses (significant vomiting) estimated at 4mL/h = 33mL/h. That's 3.5 times maintenance - which is a HEFTY dose for such a little guy. This would be for the first 6 hours, after which we would assess his hydration status (look at gum color, CRT, blood pressure, heart rate, and skin tent) and adjust his fluids accordingly.

2) Start Ampicillin at 20mg/kg IV every 8 hours in case this is leptospirosis.

3) Start a fentanyl/lidocaine CRI (constant rate infusion) for pain control.

4) Administer Cerenia 5mg SQ for nausea, as well as metoclopramide 2mg/kg/day dose in his fluids.

5) Administer Vitamin K1 12.5mg SQ once, then start on oral tablets when tolerating food

After he received fluids for a bit, I proceeded with my next step in diagnostics. As Hermit Thrush astutely pointed out, that would be imaging. If something is wonky with the liver and/or kidneys - better go and take a peek, no?

Case study part 5

Given that my top differentials were leptospirosis and some type of cancer, I proceeded to do abdominal imaging. I started with an ultrasound of the abdomen.

On u/s, an extremely large, cavitated mass that appeared to be originating from the liver or spleen was found. The kidneys could not be visualized due to the enormous mass. The stomach was small and empty of food. No abnormalities were noted. The gallbladder was normal in size and appearance. The urinary bladder was moderately full. The intestines were displaced to the caudal abdomen due to the liver mass. The spleen was not well seen. No free fluid was noted in the abdomen.

Xrays of the abdomen confirmed an enormous abdominal mass. The kidneys could not be seen on either lateral or V/D. The intestines were displaced to the caudal abdomen. The entire cranial and mid-abdomen were filled with the mass. The head of the spleen was visible on V/D and appeared normal. The mass appeared to be originating from the liver.

I also collected a urine sample and blood sample to submit for lepto titers (BEFORE instituting antibiotic therapy).

What next?

Case study part 6

Here's where it gets sticky:

My patient was very, very sick. He had a huge, huge tumor in his belly that was cavitated and horrible looking. He also had severe azotemia (elevated kidney enzymes) and significant anemia. One of his clotting times was very slightly elevated.

I was left with these questions:

1) Was the tumor causing the clinical signs, anemia, and azotemia? Was the tumor a red herring?
2) Which came first: the tumor or the kidney disease?
3) What should I do? Stabilize the patient with the hopes that the tumor could be taken out later? Or take the tumor out now?

What would you have done?

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