|
|
Polydipsic Pooch
| Complete
Blood Count |
Serum
Biochemistry Profile |
| Test |
Result |
Reference Range |
Test |
Result |
Reference Range |
| WBC K/uL |
| RBC M/uL |
| Hb g/dl |
| HCT % |
| MCV fml |
| MCH pg |
| MCHC % |
| RDW % |
| Platelets
K/ul |
| Baso /ul |
| Eos /ul |
| Polys /ul |
| Lymphs /ul |
| Monos /ul |
|
| 6.2 |
| 8.45 |
| 19.2 |
| 54.4 |
| 64 |
| 22.7 |
| 35.3 |
| 15.7 |
| 280 |
| 12 |
| 83 |
| 3940 |
| 1840 |
| 365 |
|
| 6.0-17.0 |
| 5.50-8.50 |
| 12.0-18.0 |
| 37.0-55.0 |
| 60-77 |
| 19.0-25.0 |
| 32.0-36.0 |
| 13.2-16.0 |
| 200-500 |
| 0-500 |
| 0-1250 |
| 3600-11500 |
| 1000-4800 |
| 150-1350 |
|
| Glucose mg/d |
| BUN mg/dl |
| Creatinine mg/dl |
| Sodium meq/l |
| Potassium meq/l |
| Na/K Ratio |
| Chloride meq/l |
| Carbon Dioxide meq/l |
| Total protein g/dl |
| Albumin g/dl |
| Globulin g/dl |
| Phosphorus mg/dl |
| Bilirubin total mg/dl |
| Calcium mg/dl |
| Alkaline phosphatase u/L |
| ALT u/L |
| AST u/L |
| Gamma gt U/L |
| Cholesterol mg/dl |
|
| 97 |
| 34 |
| 1.3 |
| 143 |
| 5.3 |
| 27 |
| 102 |
| 26 |
| 6.9 |
| 4.1 |
| 2.8 |
| 5.5 |
| 0.3 |
| 11.2 |
| 56 |
| 139 |
| 57 |
| 4 |
|
276 |
|
| 65-130 |
| 6-29 |
| 0.6-1.6 |
| 140-158 |
| 4.0-5.7 |
| 27-40 |
| 100-115 |
| 18-26 |
| 5.4-7.6 |
| 2.3-4.0 |
| 2.7-4.4 |
| 3.0-7.0 |
| 0.0-0.5 |
| 8.0-12.0 |
| 10-84 |
| 5-65 |
| 16-60 |
| 2-10 |
|
150-275 |
|
At this time, which
of the following should be included on your rule-out list for Chuck's PU?PD? (You
can click on each of your rule-outs to learn more).
ONE MONTH LATER:
Chuck was represented with the complaints of anorexia,
lethargy, and vomiting. The diet had been changed recently. Chuck remained
PU/PD, with no dysuria.
What are your rule-outs for Chuck's vomiting with anorexia and lethargy?
(Consider BIG categories). (Click on highlighted words for answers).
Clinicopathologic evaluation:
| CBC |
|
SERUM
BIOCHEMISTRY PROFILE |
| TEST |
RESULTS |
Reference Range |
|
TEST |
RESULTS |
Reference Range |
| WBC K/uL |
| RBC M/uL |
| Hb g/dl |
| HCT % |
| MCV fml |
| MCH pg |
| MCHC % |
| RDW |
| Platelets K/uL |
| Eos/uL |
| Bands/uL |
| Polys/uL |
| Lymph/uL |
| Monos/uL |
|
| 8.2 |
| 8.53 |
| 18.6 |
| 52.1 |
| 61 |
| 21.8 |
| 35.7 |
| 15.9 |
| 366 |
| 328 |
| 0 |
| 5330 |
| 2214 |
| 328 |
|
| 6.0-17.0 |
| 5.50-8.50 |
| 12.0-18.0 |
| 37.0-55.0 |
| 60-77 |
| 19.0-25.0 |
| 32.0-36.0 |
| 13.2-16.0 |
| 200-500 |
| 0-1250 |
| 0-300 |
| 3600-11500 |
| 1000-4800 |
| 150-1350 |
|
|
| Glucose mg/dl |
| BUN mg/dl |
| Creatinine mg/dl |
| Sodium meq/l |
| Potassium meq/l |
| Na/K Ratio |
| Chloride meq/l |
| Carbon Dioxide meq/l |
| Calcium mg/dl |
| Phosphorus mg/dl |
| Total protein g/dl |
| Albumin g/dl |
| Globulin g/dl |
| Bilirubin mg/dl |
| ALP u/L |
| ALT u/L |
| Gamma gt U/L |
| Cholesterol mg/dl |
|
| 93 |
| 129 |
| 4.7 |
| 128 |
| 8.3 |
| 15 |
| 94 |
| 11 |
| 13.8 |
| 13.9 |
| 7.4 |
| 4.0 |
| 3.4 |
| 0.3 |
| 50 |
| 42 |
| 4 |
| 329 |
|
| 65-130 |
| 6-29 |
| 0.6-1.6 |
| 140-158 |
| 4.0-5.7 |
| 27-40 |
| 100-115 |
| 18-26 |
| 8.0-12.0 |
| 3.0-7.0 |
| 5.4-7.6 |
| 2.3-4.0 |
| 2.7-4.4 |
| 0.0-0.5 |
| 10-84 |
| 5-65 |
| 2-10 |
| 150-275 |
|
Now Chuck has several new problems
detected on the clinicopathologic examination.
What are the 3 big rule-outs for azotemia? Can you rule-out any of these
in Chuck's case?
What are your rule-outs
for hyponatremia in combination with hyperkalemia?
What are your rule-outs
for hypercalcemia with hyperphosphatemia in THIS dog?
COMMENT
Hypoadrenocorticism is on the rule-out list for each of
Chuck's problems, so it should be strongly considered.
How can we diagnose
Adddison's disease without compromising the dog's urgent medical needs?
Results
|
ACTH STIMULATION TEST |
| Pre-ACTH
Cortisol |
Reference
Range |
|
Post-ACTH
Cortisol |
Reference
Range |
| 1.7
ug/dl |
0-10
ug/dl |
|
1.3
ug/dl |
8-22
ug/dl |
DIAGNOSIS: Glucocorticoid and mineralocorticoid
insufficiency
Reevaluation, approximately 1 week
later:
Clinicopathologic evaluation:
|
SERUM
BIOCHEMISTRY PROFILE |
| TEST |
RESULT |
Reference Range |
|
TEST |
RESULT |
Reference Range |
| Glucose mg/dl |
| BUN mg/dl
|
| Creatinine mg/dl |
| Sodium meq/l |
| Potassium meq/l |
| Na/K Ratio |
| Chloride meq/l |
| Carbon Dioxide meq/l |
| Calcium mg/dl |
|
| 112 |
| 30 |
| 1.2 |
| 152 |
| 5.1 |
| 30 |
| 115 |
| 27 |
| 9.8 |
|
| 65-130 |
| 6-29 |
| 0.6-1.6 |
| 140-158 |
| 4.0-5.7 |
| 27-40 |
| 100-115 |
| 18-26 |
| 8.0-12.0 |
|
|
| Phosphorus mg/dl
|
| Total protein g/dl |
| Albumin g/dl |
| Globulin g/dl |
| Bilirubin mg/dl
|
| ALP
u/L |
| ALT
u/L |
| AST u/L |
|
| 5.2 |
| 6.4 |
| 3.6 |
| 2.8 |
| 0.4 |
| 1119 |
| 361 |
| 55 |
|
| 3.0-7.0 |
| 5.4-7.6 |
| 2.3-4.0 |
| 2.7-4.4 |
| 0.0-0.5 |
| 10-84 |
| 5-65 |
| 16-60 |
|
Note, with appropriate therapy for Chuck's
Addison's disease (mineralocorticoids and glucocorticoids), his azotemia, hypercalcemia,
hyperphosphatemia, hyperkalemia, and hyponatremia have resolved.
Return to
Chuck's Physical Examination Results
|
At this time, which
of the following should be included on your rule-out list for Chuck's PU/PD? |
| Diabetes mellitus |
There was no evidence of
hyperglycemia so this possibility has been ruled-out. |
Return to PU/PD Rule Outs
| Hypercalcemia |
There was no evidence of
hypercalcemia so this possibility has been ruled-out. |
Return to PU/PD
Rule Outs\
| Renal insufficiency |
Dogs have to lose > 2/3
normal renal function to lose the ability to concentration their urine, and lose > 3/4
functional nephrons to have increased creatinine and BUN. Chuck may be one of the
rare dogs where he has lost between 2/3 and 3/4 renal function. A mildly increased
BUN with normal creatinine in a dog with normal body composition may represent a
postprandial influence, or gastrointestinal hemorrhage. |
Return
to PU/PD Rule Outs
| Pyelonephritis |
YES, this should still be on
your rule-out list. Not all dogs with pyelonephritis have increased serum
creatinine. E. coli (and other bacteria) produce endotoxin which may cause a
nephrogenic diabetes insipidus. A bacterial urinary tract infection should be
ruled-out in every dog with PU/PD. (Also, polyuria may predispose an animal to a
urinary tract infection.) |
Return to PU/PD Rule Outs
| Hyperadrenocorticism |
YES, this should still be on
your rule-out list. Not all dogs with hyperadrenocorticism have stress leukograms
and increased concentrations of alkaline phosphatase. Hyperadrenocorticism is a common
cause of PU/PD in dogs. |
Return to PU/PD Rule Outs
| Hypoadrenocorticism |
YES, this should still be on
your rule-out list. Not all dogs with hypoadrenocorticism have mineralocorticoid
insufficiency. Some glucocorticoids are needed for normal renal tubular function;
without any, tubular dysfunction may occur. It would be uncommon to diagnose
Addison's disease in dogs with PU/PD as the only abnormality (but it should be considered
in every PU/PD dog). |
Return to PU/PD Rule Outs
| Diabetes insipidus |
Although central diabetes
insipidus is rare, several relatively common abnormalities may cause nephrogenic diabetes
insipidus (Cushings, hypercalcemia, endotoxins). This should still be on your
rule-out list. |
Return to PU/PD Rule Outs
| Hypothyroidism |
Although
hypothyroidism-associated polyuria is rare, this should be on your rule-out list in a dog
where there is other physical examination and historical findings compatible with
hypothyroidism. None of Chuck's physical examination findings or recent history was
supportive on hypothyroidism. |
Return to PU/PD Rule Outs
| Psychogenic |
Although psychogenic
polydipsia is very rare, this should remain a potential rule-out for Chuck's PU/PD. |
Return to PU/PD
Rule Outs
|
What are your rule-outs for vomiting with anorexia and lethargy?
(Consider BIG categories). |
|
Polysystemic diseases
(uremia, hepatic disease, hypoadrenocorticism, etc ) or primary GI disease. |
Return to
discussion of Chuck's onset on vomiting
|
What are the 3 big rule-outs for azotemia? |
|
Prerenal, renal,
postrenal. These cannot be differentiated by the value of the BUN, creatinine,
phosphorus, or any other blood or urine test. One cannot predict reversibility of
the azotemia based on a single blood sample. In Chuck's case, there has been no history of
trauma or dysuria, so we can rule-out postrenal azotemia. |
Return to discussion
of new problems.
|
What are your rule-outs for hyponatremia in combination with
hyperkalemia? |
|
The number one rule-out
should be hypoadrenocorticism. Other rule outs to consider: severe diarrhea
(especially large bowel, trichuriasis), renal failure, heart failure. |
Return to discussion
of new problems.
|
What are
your rule-outs for hypercalcemia with
hyperphosphatemia in THIS dog? |
|
A) Primary hypercalcemia |
(neoplasia,
hyperparathyroidism, vitamin D intoxication) leading to prerenal or renal azotemia |
|
B) Hypoadrenocorticism |
Hypoadrenocorticism causing
hypercalcemia, and hypoadrenocorticism causing prerenal azotemia with resulting
hyperphosphatemia. |
Return to discussion
of new problems.
|
How can we diagnose Addison's disease without compromising the dog's
urgent medical needs? |
| Provide fluid support (0.9
% NaCl) to re-establish normal intravascular volume and to decrease the
hyperkalemia, monitoring cardiovascular status. |
| Perform an ACTH stimulation
test. |
| After collection of the
postACTH sample, you can administer parenteral dexamethasone. |
Return to discussion of
Addison's disease.
|
