signalment: 2.5 y, male, great dane
history : 四個月內急瘦50 lb. body condition 1 out of 9. 食慾尚可, 沒有嘔吐也沒有拉肚子, 主人說狗都要花20分鐘以上才尿的出來，沒有Pu/PD, 五個月以前接種過狂犬病疫苗
血檢
RBC 3.81 (5.5-8.5)
Hb 8.8 (12-18)
HCT 26.3 (37-55)
MCV 69.1 (60-77)
MCH 23.1 (19-24)
MCHC 33.4 (32-36)
RDW 17.9 (11-17)
REtic (11.5 (0-1)
absolute retic 436,000 (0-60,000)
nRBC 2
plt 120 (150-450)
MPV 14.6 (8.4-13)
plt estimate decreased
WBC 24,350 (6000-17000)
Neu 19237 (3000-11400)
Bands 0
Lymph 2679 (1000-4800)
Mono 1192 (150-1350)
eos 244 (100-750)
comments: marked anisocytosis, few macrocyties, slight hypochromasia, slight poikilocytosis, slight polychromasia, few target cells, moderate large plts
chemistry
total protein 5 (5.1-7.3)
alb 2.5 (2.6-3.5)
Glb 2.5 (2.6-5)
SAP 137 (4-95)
ALT 275 (26-200)
AST 224 *(15-50)
total bili 33.4 (.1-.3)
CK 221 (92-357)
BUN 144 (10-25)
Cret 11.6 (0-1.3)
Calcium (11.3 (9.5-11.8)
phosphate 18.5 (3.3-5.8)
glucose 82 (80-100)
cholesterol 64 (68-224)
bicarbonate 14.5 (13.9-23.1)
sodium 124 (146-160)
K 3.4 (3.5-5.9)
Cl 87 (108-125)
Anion gap ?? (11.8-23.1)
Osmolality (Cal) ?? (295-317)
Iron 189 (100-220)
UA (catheterized)
color amber
turbidity sl. cloudy
SG 1.011
pH 5.5
protein 53.0
glu (-)
Ketone (-)
blood 3+
Bilirubin 3+
urobilinogen 0.2
sediment rare WBC, 10-20 RBC/HPF, 0-3 epi, a few sperm, mod amorphous crystals.
大家來討論一下吧
4 則留言:
這個case非常的奇怪
final diagnosis竟然是ICH
1. stress lukocytosis + regenerative normocytic normochromic anemia.
好像快要變成non-regenerative anemia
2. A G = 124 + 3.4 - (87 + 14.5) = 25.9 ---↑
Osmolality = 1.86(124 + 3.4) + 82/18 + 144/2.8 + 9
= 237+4.5+51.4+9 = 301.9---normal
3. bicarbonate 14.5 (13.9-23.1), sodium 124 (146-160), K 3.4 (3.5-5.9), Cl 87 (108-125), Anion gap 25.9 (11.8-23.1)----混合型代謝性酸鹼中毒+酸尿(by renal insufficiency?) 應該有嘔吐吧?
4. BUN 144 (10-25), Cret 11.6 (0-1.3), phosphate 18.5 (3.3-5.8),+ UA SG 1.011, protein 53.0, severe renal insufficiency, 腎無濃縮功能, 蛋白漏出, 這樣不會嘔吐??
5. alb 2.5 (2.6-3.5), Glb 2.5 (2.6-5), SAP 137 (4-95), ALT 275 (26-200), AST 224 *(15-50), total bili 33.4 (.1-.3) + UA Bilirubin 3+ , urobilinogen 0.2---hepatitis, liver insufficiency, 這樣應該會有厭食,黃疸和嘔吐吧?
6. 不懂會甚麼是ICH(infectious canine hepatitis)? 沒打預防針? 有驗出病毒? 有 blue eye? 如果是ICH有可能因為Ag-Ab complex 引起renal insufficiency, 不過沒碰過這麼嚴重的, 有沒可能有其他合併疾病? 有其他證據?? 真的好奇怪呢!
又去複習ICH, 先侵犯hepatocyte, renal tubular epitheliocyte, vascular endotheliocyte--->hepatitis, tubular necrosis, vasculitis,DIC, 之後 Ag-Ab complex 沉積--->blue eye,glomerulonephritis
而感染過程有可能從acute-->chronic-->persistent
wa~ 那這個病例等於快要從頭到尾走一遍了...
ARF-->CRF, acute hepatitis-->chronic hepatitis-->cirrhosis,
所以 alb 2.5 (2.6-3.5), Glb 2.5 (2.6-5), glucose 82 (80-100), cholesterol 64 (68-224), total bili 33.4 (.1-.3) 才偏低?? 那不就快要hyperammonaemia? 需要做肝功能試驗??
Hyperbilirubinemia + Retic 11.5 (0-1) + UA- Bilirubin 3+--> hemolytic anaemia
marked anisocytosis, few macrocyties, slight hypochromasia, slight poikilocytosis, slight polychromasia, few target cells, moderate large plts-->慢性失血, DIC, RBC脆性增加, 缺鐵, liver disease, 已經過4個月, 再加上renal insufficiency, liver insufficiency --> alb 2.5 (2.6-3.5), Glb 2.5 (2.6-5), UA- protein 53.0 好複雜的結果... 快要non-regenerative anemia.....
大丹對ICH的抵抗力這麼差? 還是因為rabies vaccine的關係? 會不會有leptospirosis?? 很好奇預後不知如何? 已經很久沒碰到ICH了...
花20分鐘以上才尿的出來，sediment rare WBC, 10-20 RBC/HPF, 0-3 epi, a few sperm, mod amorphous crystals.
-->post-renal azotaemia?可是electrolyte 不符,如果沒有嘔吐沒有拉肚子也沒有PU/PD,加上Osmolality normal,倒像是fluid therpy or diuretic的結果,再不就真是CRF-->electrolyte+protein loss...
想到甚麼寫甚麼...sorry,亂寫一通 ~~"
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