Wednesday, November 4, 2009

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?

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