11 year old intact male miniature schnauzer
History: intermittent vomiting and diarrhea for last 2 weeks
physical exam : tense, painful abdomen, very fat
CBC::PCV:38(3-55)
RBC 13.2(12-18)
Hb 5.7(5.5-8.5)
MCV:67 (60-72)
MCHC 35 (34-38)
REtic N/A
NCC : 17.9 (6-17)
Bands 0.5 (0-0.3)
Segs 14.2(3-11.5)
Lymphs: 2.5 (1-4.8)
Monos 0.7 (0.1-1.3)
plt : 250 (200-500)
TP 9 (6-8)
biochem
Glu:124 (65-122)
BUN 42 (7-28)
Creat 1.2 (0.9-1.7)
Ca 9.8(9-11.2)
Phos 5.8(2.8-6.1)
TP 7.7(5.4-7.4)
Alb:3.7 (2.7-4.5)
Glob: ??? (1.9-3.4)
T. bili 10.8 (0-0.4)
Chol 1230 (130-370)
ALT 600 (10-120)
ALP 660 (35.280)
Na 148 (145-158)
K 4.3 (4.1-5.5)
CL 110(106-127)
tCO2 24 (14-27)
AG ?? (8-25)
Amylase 510 (50-1250)
Lipase 120 (30-560)
UA (Catherterized)
color : yellow/cloudy
SG: 1.022
Pt : 3+
Glu : Neg
bili: 2+
blood: Neg
pH 7.0
sediment
WBC >50
RBC 0-1
Epi 0 tranitional 0 No casts, crystals
bacteria : many bacilli
我想可能還是來做biochem好了 Cytology就等我回去慢慢教好了
3 則留言:
I've been waiting for a month...yet still nobody wanna answer.
Just my 2 cents.
FINDINGS:
1. Very mild neutrophilia with left shift
2. Elevated BUN without elevated creatinine
3. Hypercholesterolaemia and severe jaundice without anaemia
4. Elevated ALT and ALP
5. Mildly elevated TP
6. AG = (148 + 4.3) - (110 + 24)
= 18.3 (normal)
7. Bilirubinuria, pyuria with lots of WBC.
DISCUSSION:
1. From the above findings, many people know to rule hepatic problem in. In face of dehydration, TP and albumin may falsely elevated but I don't think significant hypoalbuminaemia would be seen after correction of hydration status. I doubt if this is primary liver disorder.
2. Bile outflow obstruction is another concern for elevated liver enzyme, severe jaundice, painful abdomen and GI symptoms. And beware of biliary mucocele. A good ultrasonography is very useful for next step.
3. For an obese schnauzer, with lipemia, painful abdomen and GI signs, I should always put pancreatitis in my differential list. According to recent study, around 30 to 60% of histopathological confirmed pancreatitis dogs show normal lipase and amylase value. The reasons may be exhausted enzyme, altered activity and increased clearance, etc. You may read those studies if having a great interest. Elevated liver enzymes with variable WBC counts match pancreatitis, too.
4. Pyuria may be an incidental findings and may be not. Culture and sensitivty should be highly suggested. Remember, a septic dog may show elevated liver enzyme, too. I don't know the vaccination status and so like to pull leptospirosis in my differentials. For intact male dog, prostatic abscess is very painful...It hurts!
5. Other differentials include Cushing's, peritonitis, foreign bodies,..etc.
MY BET (In descending order)
1. Bilious outflow obstruction with or without gall bladder rupture.
2. Bilious mucocele
3. Pancreatitis
4. Cholangiohepatitis
5. Other primary hepatic insult
6. UTI with or without sepsis
7. Prostatic abscess
8. Cushingnoids
馬先生真利害，我發現果然臨床獸醫列出的dif都好多，我可能只能列出三項吧...不過，你知道，臨床醫師看臨床症狀講話，臨床病理看數據說話，基本上會有些許的差異。比如說胰臟炎，大概是不會出現在我的list上頭。還有prostatic abscess也沒有特殊的血相可以看的出來，除非cytology一下，我想普遍應該不會come up with這個dif吧。不過臨床醫師可能會想的比較周到:)
。
回到家, 可以打中文了.
哈..基本上是GP們對個別輔助診斷學科學得不夠, 所以會多羅列一些有的沒的 :P 每次去上影診/細胞/內科臨病這些課的時候, 發現在病例討論的時候, 講師都會說: 因為現在沒看到XXX, 所以YYY不太像, 頂多放在鑑別診斷list的最後面...
:)
就個人經驗, 是看過一些amylase / lipase都沒上升的pancreatitis, 但沒看過造成那麼厲害的黃疸.Prostatic abscess / Cushingnoids亦然.
不過, 如果是bilious outflow obstruction再加pancreatitis呢? 這個就只得把超音波探頭拿出來了.
不過就GP的能力而言, 要正確用超音波診斷pancreatitis, 有一點難度.
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