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Clinical Cases Focus on Respiratory and Cardiology - rossskb

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Clinical Cases Focus on Respiratory and Cardiology - rossskb Powered By Docstoc
					         Clinical Cases
Focus on Respiratory and Cardiology

    Dusty W. Nagy, DVM, MS, PhD DACVIM
             University of Missouri
      Food Animal Medicine, Surgery, and
             Production Medicine
              Case Workup
Signalment
History
Physical Examination
Problem List
Differential Diagnoses
– Prioritized list
– Avoid zebras
     particularly the pink and chartreuse ones
              Case Workup
Initial diagnostic and treatment plan
– Prioritize tests
    Utility – rule in or rule out differentials
    Need to know info for treatment
– Analyze test results
Changes to the plan
Outcome
Reflection
Case 1
Chief complaint: weak, appears drunk
Signalment: 9-year-old black crossbred cow
History: Cow was seen off by herself this
morning. They assumed that she was trying
to calve. When no calf was noted by noon
they went to check on her. She rushed the
owner and rammed several farm vehicles
while taking her to the barn.
Environment: August in central Missouri.
Cow is one of 32 in a cow calf herd. They are
housed on 80 acres of mostly fescue grass
subdivided into 3 pastures.
                        University of Missouri #
        Physical Examination
Appearance                  Urine analysis
Body condition score 5/9    yellow/orange color
Normal abdominal contour    No analysis done
Behavior                    TPR
Belligerent                 Temperature – 104.2 ºF
Aggressive                  Pulse – 92 bpm
Gait and posture            Respiratory rate – 52 bpm
Weak
Stands base wide on all 4
Sways while walking
Physical Examination – left side
                        Lung auscultation
 Rumen
                        normal breath sounds
 Decreased content
 Poor stratification
                        Heart auscultation
                        Rhythm – regular, fast
 Pings
                        Intensity – normal
 No pings
                        Sounds – no murmurs or
 Lymph Nodes              arrhythmias
 prefemoral – normal    Jugular vein
 prescapular - normal   Normal
                        Cervical skin tent
                        < 2 seconds
Physical Examination – right side
Pings                  Lung auscultation
No pings               Normal breath sounds
Seccussion             Heart auscultation
No fluid sloshing      Rhythm – regular, fast
Ballotment             Intensity – normal
normal                 Sounds – no murmurs or
                         arrhythmias
Lymph nodes
                       Jugular vein
Prefemoral – normal
                       Normal
Prescapular - normal
                       Cervical skin tent
                       < 2 seconds
       Physical Examination
Abdominal pain    Head
None present      Ocular discharge - none
Skin              Eye examination - normal
normal            Nasal discharge - none
Extremities       Mucous membrane color -
normal              yellow
                  Teeth - normal
Musculoskeletal
normal
       Physical Examination
Mammary gland              Rectal palpation
Inflammation                Third trimester fetus
  none present             Feces
Strip cup                   Dry/firm
  no abnormalities          Large amount in rectum
California mastitis test




                   Problem list
           Problem list
Tachycardia
Tachypnea
Fever
Jaundice
Abnormal behavior, posture and gait
Abnormal fecal consistency


      Prioritized list of differentials
        Differential diagnosis
Tachycardia/Tachypnea
– Cardiac disease
– Respiratory disease
– Disease that affects oxygen carrying capacity
– Pain
– Stress
Jaundice
– Liver failure
– Hemolysis
    Intravascular
    Extravascular
        Differential diagnosis
Fever
– Infection
– Inflammation
Abnormal posture and gait
– Neurologic disease
– Musculoskeletal disease
– Disease that affects oxygen carrying capacity
Abnormal fecal consistency
– Gastrointestinal disease
– Dehydration
        Initial diagnostic and treatment plan
Diagnostic plan Treatment plan
 CBC                  Antibiotics
  – PCV/TP            – Oxytetracycline 9mg/lb
                        SQ EOD
                      Low stress
                      environment
 Arterial blood gas
 Serum biochemistry
 Urinalysis
 Complement
 fixation/PCR
             Interpretation
CBC
Anemia – loss
Anisocytosis
Polychromasia
Erythrocyte basophilic stippling
Peripherally located erythrocyte parasites
Update – after 2 days the cow is picking at
hay and drinking some water. She is
sticking close to the barn, but is moving
around the lot.
Do you want to do any additional diagnostics or
change treatments?
   The rest of the bunch…..
Do you want to do anything for the rest of
the herd?
Does geography matter?
Does herd type matter?
Can you clear the carrier state?
          What if’s………
What if the cow was down with a PCV of
8?
– Would you transfuse her?
– Would you treat her?
– Would you euthanize her?
    Any considerations before?
CASE 2
Problem: drooling, respiratory noise
Signalment: 6-month-old crossbred steer
History: 10 calves (including patient) were
weaned, vaccinated, castrated, and
dehorned if necessary approximately 2
weeks prior. The calf did not eat as well as
expected yesterday. Today it is anorexic and
honks on inspiration.
Environment: June in central Missouri. Herd
composed of 50 cow/calf pairs on fescue
pasture. Calves get some supplemental
grain.
                        University of Missouri #
        Physical Examination
Appearance                 Urine analysis
Body condition score 4/9   – None caught
Normal abdominal contour   TPR
Behavior                   Temperature – 104.8 ºF
Mildly distressed          Pulse – 80 bpm
Gait and posture           Respiratory rate – 56 bpm
Head and neck extended
Physical Examination – left side
 Rumen                    Heart auscultation
 Normal stratification
                          Rhythm - regular
 Pings                    Intensity - normal
 No pings
                          Sounds – no murmurs or
 Lymph Nodes                arrhythmias
 prefemoral – normal
                          Jugular vein
 prescapular – normal
                          Normal
 Lung auscultation
 Difficult to auscult
                          Cervical skin tent
 Honking on inspiration   < 2 seconds
 Open mouth breathing
Physical Examination – right side
                       Lung auscultation
Pings
                       Difficult to auscult
No pings
                       Honking on inspiration
Seccussion             Open mouth breathing
No fluid sloshing      Heart auscultation
Ballotment             Rhythm – regular
normal                 Intensity – normal
Lymph nodes            Sounds – no murmurs or
                         arrhythmias
Prefemoral – normal
Prescapular - normal
                       Jugular vein
                       Normal
                       Cervical skin tent
                       < 2 seconds
       Physical Examination
Abdominal pain    Head
None present      Ocular discharge - none
Skin              Eye examination – mild scleral
normal              injection
Extremities       Nasal discharge –
                    whitish/yellow, fetid
normal
                  Mucous membrane color - pale
Musculoskeletal   Mouth
normal              Teeth – normal
                    Hypersalivation
                  Neck – large, painful larynx
       Physical Examination
Mammary gland              Rectal palpation
Inflammation                NA
  NA                       Feces
Strip cup                   normal
  NA
California mastitis test
  NA




                   Problem list
           Problem list
Fever
Tachypnea
Inspiratory noise
Head and neck extended
Open mouth breathing
Fetid breath
Nasal and oral discharge
Scleral injection
      Prioritized list of differentials
        Differential diagnosis
Tachypnea, inspiratory noise, head and
neck extended, open mouth breathing, fetid
breath, nasal discharge, salivation, swollen
larynx with pain
– Upper airway disease
    Necrotic laryngitis – Fusobacterium necrophorum
    Laryngeal trauma – abscess or edema
    Viral laryngitis – IBR
    Actinobacillosis
Fever, scleral injection
– Inflammation, infection
        Initial diagnostic and treatment plan
Diagnostic plan Treatment plan
 No diagnostics      Antibiotics
  – Save money for   – Florfenicol
    treatment             9 mg/lb IM EOD
                     Anti inflammatory
                     – Flunixin meglumine
                          1.1mg/kg IV SID – BID



 Endoscopy
 Radiographs
 CBC
Update – After 48 hours the steer is no
longer honking and less dyspneic. The
respiratory rate is still elevated and the
breath is still somewhat foul smelling.




 Do you want to do any additional diagnostics or
 change treatments?
          Drug Options
Florfenicol
Ceftiofur
Tulathromycin
Tilmicosin
Danofloxacin
Tetracycline
Penicillin
Sulfonimides
Case 3
Problem: respiratory distress
Signalment: Weaned crossbred beef steer
History: Calf was purchased at a sale barn in
northern Missouri with 49 other calves. It was
transported to a small feedlot in west central
MO where it was vaccinated on arrival.
Previous health and vaccine information
unknown. Calf pulled for treatment this
morning.
Environment: 1000 animal feedyard. No
testing done. Calves are routinely purchased
and combined into muti-source pens.
                         University of Missouri #
Dyspnea
        Physical Examination
Appearance                 Urine analysis
Body condition score 5/9   None caught
Gant                       TPR
Behavior                   Temperature – 105.4 ºF
Depressed                  Pulse – 76 bpm
Gait and posture           Respiratory rate – 54 bpm
Head and neck extended
Physical Examination – left side
                         Lung auscultation
 Rumen                   Loud and harsh
 Normal stratification   Crackles and wheezes
 Pings                   Rapid, shallow breaths

 No pings                Heart auscultation
                         Rhythm - regular
 Lymph Nodes             Intensity - normal
 prefemoral – normal     Sounds – no murmurs or
 prescapular - normal       arrhythmias
                         Jugular vein
                         Normal
                         Cervical skin tent
                         4 seconds
Physical Examination – right side
Pings                  Lung auscultation
                       Loud and harsh
No pings
                       Crackles and wheezes
Seccussion             Rapid, shallow breaths
No fluid sloshing      Heart auscultation
Ballotment             Rhythm – regular
normal                 Intensity – normal
                       Sounds – no murmurs or
Lymph nodes               arrhythmias
Prefemoral – normal    Jugular vein
Prescapular - normal   Normal
                       Cervical skin tent
                       4 seconds
       Physical Examination
Abdominal pain    Head
None present      Ocular discharge - mucopurulent
Skin              Eye examination - normal
normal            Nasal discharge - mucopurulent
Extremities       Mucous membrane color - pale
normal            Teeth - normal
Musculoskeletal
normal
       Physical Examination
Mammary gland              Rectal palpation
Inflammation               NA
  NA                       Feces
Strip cup                   normal
  NA
California mastitis test
  NA




                   Problem list
           Problem list
Fever
Tachypnea
Ocular and nasal discharge
Head and neck extended
Rapid shallow breathing
Abnormal lung sounds


      Prioritized list of differentials
        Differential diagnosis
Tachypnea; ocular and nasal discharge;
head and neck extension; rapid, shallow
breathing; abnormal lung sounds
– Pneumonia
    Viral
     – BRSV, IBR, PI3
    Bacterial
     – Manheimia haemolytica, Histophilus somnii, Pasturella
       multocida



Fever
– Inflammation, infection
            Initial diagnostic and treatment plan
Diagnostic plan Treatment plan
 None save money for   Antibiotics and
 treatment             Anti inflammatory
                       – Resflor gold
                            Florfenicol
                              – 40 mg/kg
                            Flunixin meglumine
                              – 2.2 mg/kg IV

 Arterial blood gas
 CBC                   Dosed at 6ml/100 lbs
                       SQ
 Radiographs
            Interpretation
      should you so choose to run tests


CBC
Neutrophilia – inflammatory disease
Neutropenia – inflammatory disease, endotoxemia
Left shift
Toxic change in neutrophils
Hyperfibrinogenemia – inflammatory disease
Update – six hours after the initial
treatment the calf is noticeably improved.
The calf’s temperature is 102.0 F,
respiratory rate and effort are within
normal limits. The calf is starting to eat
and drink. Auscultation still reveals
abnormal lung sounds.



 Do you want to do any additional diagnostics or
 change treatments?
Case 4
Problem: Sick
Signalment: 7-year-old Holstein bull
History: ADR for approximately 2 weeks.
Treated with antibiotics (several), flunixin
meglumine, and several additional
substances with no response.
Environment: Bull resides on Amish farm.
Used to breed cows for the owner and
several neighbors.

                          University of Missouri #
        Physical Examination
Appearance                 Urine analysis
Body condition score 3/5   None caught
Behavior                   TPR
QAR                        Temperature – 102.5 ºF
Gait and posture           Pulse – 92 bpm
Slight arch to back        Respiratory rate – 32 bpm
Physical Examination – left side
                       Lung auscultation
 Rumen
                       normal breath sounds
 Decreased fill
                       Heart auscultation
 Pings
                       Rhythm - UTD
 No pings
                       Intensity - UTD
 Lymph Nodes           Sounds – abnormal
 prefemoral – normal
                       Jugular vein
 prescapular – sl.
                       Distended with pulses
   enlarged
                       Cervical skin tent
                       5 seconds
Physical Examination – right side
Pings                 Lung auscultation
No pings              Normal breath sounds
Seccussion            Heart auscultation
No fluid sloshing     Rhythm – UTD
Ballotment            Intensity – UTD
normal                Sounds – abnormal
Lymph nodes           Jugular vein
Prefemoral – normal   Distended with pulses
Prescapular – sl.     Cervical skin tent
  enlargement         5 seconds
       Physical Examination
Abdominal pain    Head
Elbows abducted   Ocular discharge - none
Skin              Eye examination - normal
normal            Nasal discharge - none
Extremities       Mucous membrane color - pink
normal            Teeth - normal
Musculoskeletal
normal
Venous Distention
Jugular Pulses
Cardiac Auscultation new
Venous Pulsation
       Physical Examination
Mammary gland              Rectal palpation
Inflammation               weak aortic pulse
  NA                       Feces
Strip cup                   normal
  NA
California mastitis test
  NA




                   Problem list
            Problem list
Increased pulse rate
Abnormal cardiac auscultation
Distended jugular veins with pulses
Abducted elbows
Arched back



      Prioritized list of differentials
         Differential diagnosis
Increased pulse rate, abnormal cardiac
auscultation, distended jugular veins, jugular
pulses
– Heart failure
    Pericarditis
    Valvular endocarditis
    Lymphosarcoma
Abducted elbows, arched back
– Pain
    Cranial abdominal/caudal thoracic


         Initial diagnostic and treatment plan
Diagnostic plan Treatment plan
 Serious talk with     Euthanasia
 owner



 Echocardiogram ????
 CBC
 BLV serology/PCR
  – Cancer hunt
Septic Pericarditis

				
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posted:12/4/2012
language:English
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