SAMPLER Blackwell’s Five-Minute Veterinary Consult Clinical Companion About the Series Case Study and Answers Table of Contents Chapter 1 Appendix Index About the Series • Features the familiar Five-Minute • Authoritative coverage of: Veterinary Consult framework o Canine and Feline Behavior o Canine and Feline Infectious • Builds on sections of the species- Diseases and Parasitology specific consults, with more detail o Small Animal Emergency and on each topic and additional Critical Care topics included o Small Animal Dermatology o Small Animal Toxicology • Carefully organized with bulleted o Small Animal Dentistry information for quick search and o Small Animal Endocrinology easy reference and Reproduction o Equine Theriogenology • Full-color photographs • Written by subject experts • Companion website (or CD) with client handouts and/or case studies (select titles) Clinical Case Study (available on the companion website) Terrible turn in toxicology You are excited that your first senior rotation is two weeks at a regional animal poison control center. The center provides public services as well as veterinarians professional guidance. You get to answer the phones with a supervising veterinary toxicologist. At 2 am during your first shift a small animal practice veterinarian calls about a 1-year-old rat terrier that she thinks has ingested some sort of toxin. She is driving into town as she calls so the information she relates is from her technician who has reached the clinic and has initiated lab work already. Apparently, two days ago the dog was accidentally trapped in the neighbor’s garage overnight and most of the next day. The owners had been searching for him and when they finally located him in the garage he was vomiting profusely and had diarrhea. They thought he must have gotten into something as he was perfectly fine before that and the neighbor’s garage had every possible piece of junk, food, yard equipment and an assortment of chemicals for his vehicles, lawn, home, etc. The referring vet stated the dog’s initial lab showed a markedly elevated Ca++ and moderately elevated PO4. The technician was horrified that his Ca++/PO4 ratio was exceptionally high! The dog reportedly looked dehydrated but had isosthenuric urine. His BUN and creatinine were elevated and a CBC indicated hemoconcentration and a mild stress leukogram. He was depressed and still vomiting when the technician called you. You had just finished Toxicology 426 so you knew the three top differentials, the tests you would do to confirm your diagnosis and how you would start treatment. 1. Of the following, which would best characterize the toxicosis described and the top 3 differential diagnoses for the “Terrible Turn in Toxicology”? Student Response Value Correct Answer Feedback 1. Nephrotoxin = ethylene glycol, aflatoxin, raisins 2. Hepatotoxin = cholecalciferol, ethylene glycol, aflatoxin 3. Nephrotoxin = cholecalciferol, ethylene glycol, raisins 4. Nephrotoxin = raisins, bromethalin, lilies 5. Nephrotoxin = arsenic, bromethalin, grapes 1 2. For the differential list you selected (Terrible Turn in Toxicology), which combination of tests would most clearly support the correct diagnosis? Student Response Value Correct Answer Feedback 1. azotemia, isosthenuria, leukocytosis 2. azotemia, hypocalcemia, isosthenuria 3. acidosis, hypocalcemia, hyperosmolality 4. acidosis, hypercalcemia, hyposthenuria 5. azotemia, hypercalcemia, isosthenuria 6. azotemia, cholestasis, hyperbilirubinemia 7. azotemia, hyperglycemia, isosthenuria 3. Given the circumstances for our dog in this “Terrible Turn”, select a potential treatment regimen you would recommend for a client with limited financial resources. You may choose 2 options. Student Response Value Correct Feedback Answer 1. Activated charcoal initially This is a good start because it monitors important and again at 12 hours; start parameters, but it doesn’t have a contingency for using a IV saline, furosemide and more powerful drug to reduce calcium. Early therapy corticosteroid; monitor may forestall the need for D3 drug antidote. serum calcium, BUN and UA specific gravity 2. Emesis, cathartic, activated Patient has already been vomiting, and adequate charcoal, IV fluids and start laboratory evaluation has not been done. on salmon calcitonin q6h for 4 days; monitor BUN and UA specific gravity 3. Activated charcoal initially This choice provides excellent upfront detoxification and again at 12 hours; start (charcoal twice) and monitoring with a decision point IV saline, furosemide and that is specific (Ca @ 14 mg/dL); still allows client input corticosteroid; monitor if the decision point comes. serum calcium, BUN and UA specific gravity; start salmon calcitonin if serum Ca > 14 mg/dL 4. Activated charcoal initially This choice provides excellent upfront detoxification and again at 12 hours; start (charcoal twice) and monitoring with a decision point 2 IV saline, furosemide and that is specific (Ca @ 14 mg/dL); still allows client to corticosteroid; monitor decide about pamidronate therapy if conditions worsen. serum calcium, BUN and Remember, the reduced number of doses may keep UA specific gravity; start down total drug use as well as reduce hospital care costs. pamidronate if serum Ca > 14 mg/dL 5. Start pamidronate and IV Overkill without proper evaluation of patient status. fluids, continue until UA is normal 4. If this case had terminated as a fatality without being submitted for antemortem veterinary care, which of the following could you use to confirm toxicosis in a cost-effective manner? SELECT 3. Student Response Value Correct Answer Feedback 1. Radiography of the renal area for increased Option if necropsy is not radiodensity of the kidneys related to desired calcium content 2. Targeted necropsy of heart, GI tract and Allows for confirmation of kidneys with submission for histopathology diagnosis by traditional exam histopathology 3. Chemical analysis of kidney for the toxic Many labs don’t have the metabolite capability to find metabolites 4. Chemical analysis of kidney for calcium Inexpensive and readily content available assay 5. Chemical assay for primary toxicant in liver Expensive and many labs and metabolites in liver and kidney don’t offer both primary toxicant and secondary metabolites 3 Clinical Case Study Answers (available on the companion website) Terrible turn in toxicology You are excited that your first senior rotation is two weeks at a regional animal poison control center. The center provides public services as well as veterinarians professional guidance. You get to answer the phones with a supervising veterinary toxicologist. At 2 am during your first shift a small animal practice veterinarian calls about a 1-year-old rat terrier that she thinks has ingested some sort of toxin. She is driving into town as she calls so the information she relates is from her technician who has reached the clinic and has initiated lab work already. Apparently, two days ago the dog was accidentally trapped in the neighbor’s garage overnight and most of the next day. The owners had been searching for him and when they finally located him in the garage he was vomiting profusely and had diarrhea. They thought he must have gotten into something as he was perfectly fine before that and the neighbor’s garage had every possible piece of junk, food, yard equipment and an assortment of chemicals for his vehicles, lawn, home, etc. The referring vet stated the dog’s initial lab showed a markedly elevated Ca++ and moderately elevated PO4. The technician was horrified that his Ca++/PO4 ratio was exceptionally high! The dog reportedly looked dehydrated but had isosthenuric urine. His BUN and creatinine were elevated and a CBC indicated hemoconcentration and a mild stress leukogram. He was depressed and still vomiting when the technician called you. You had just finished Toxicology 426 so you knew the three top differentials, the tests you would do to confirm your diagnosis and how you would start treatment. 1. Of the following, which would best characterize the toxicosis described and the top 3 differential diagnoses for the “Terrible Turn in Toxicology”? Student Response Value Correct Answer Feedback 1. Nephrotoxin = ethylene glycol, aflatoxin, raisins 2. Hepatotoxin = cholecalciferol, ethylene glycol, aflatoxin 3. Nephrotoxin = cholecalciferol, ethylene glycol, 100% raisins 4. Nephrotoxin = raisins, bromethalin, lilies 5. Nephrotoxin = arsenic, bromethalin, grapes 1 2. For the differential list you selected (Terrible Turn in Toxicology), which combination of tests would most clearly support the correct diagnosis? Student Response Value Correct Answer Feedback 1. azotemia, isosthenuria, leukocytosis 2. azotemia, hypocalcemia, isosthenuria 3. acidosis, hypocalcemia, hyperosmolality 4. acidosis, hypercalcemia, hyposthenuria 5. azotemia, hypercalcemia, isosthenuria 100% 6. azotemia, cholestasis, hyperbilirubinemia 7. azotemia, hyperglycemia, isosthenuria 3. Given the circumstances for our dog in this “Terrible Turn”, select a potential treatment regimen you would recommend for a client with limited financial resources. You may choose 2 options. Student Response Value Correct Feedback Answer 1. Activated charcoal initially 50% This is a good start because it monitors important and again at 12 hours; start parameters, but it doesn't have a contingency for using a IV saline, furosemide and more powerful drug to reduce calcium. Early therapy corticosteroid; monitor may forestall the need for D3 drug antidote. serum calcium,