Transcript Clinical Cases Focus on Respiratory and Cardiology

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
Body condition score 5/9
Normal abdominal contour
Behavior
Belligerent
Aggressive
Gait and posture
Weak
Stands base wide on all 4
Sways while walking
Urine analysis
yellow/orange color
No analysis done
TPR
Temperature – 104.2 ºF
Pulse – 92 bpm
Respiratory rate – 52 bpm
Physical Examination – left side
Rumen
Decreased content
Poor stratification
Pings
No pings
Lymph Nodes
prefemoral – normal
prescapular - normal
Lung auscultation
normal breath sounds
Heart auscultation
Rhythm – regular, fast
Intensity – normal
Sounds – no murmurs or
arrhythmias
Jugular vein
Normal
Cervical skin tent
< 2 seconds
Physical Examination – right side
Pings
No pings
Seccussion
No fluid sloshing
Ballotment
normal
Lymph nodes
Prefemoral – normal
Prescapular - normal
Lung auscultation
Normal breath sounds
Heart auscultation
Rhythm – regular, fast
Intensity – normal
Sounds – no murmurs or
arrhythmias
Jugular vein
Normal
Cervical skin tent
< 2 seconds
Physical Examination
Abdominal pain
None present
Skin
normal
Extremities
normal
Musculoskeletal
normal
Head
Ocular discharge - none
Eye examination - normal
Nasal discharge - none
Mucous membrane color yellow
Teeth - normal
Physical Examination
Mammary gland
Rectal palpation
Inflammation
none present
Strip cup
no abnormalities
California mastitis test
Third trimester fetus
Feces
Dry/firm
Large amount in rectum
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
– PCV/TP
Arterial blood gas
Serum biochemistry
Urinalysis
Complement
fixation/PCR
Antibiotics
– Oxytetracycline 9mg/lb
SQ EOD
Low stress
environment
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
Body condition score 4/9
Normal abdominal contour
Behavior
Mildly distressed
Gait and posture
Head and neck extended
Urine analysis
– None caught
TPR
Temperature – 104.8 ºF
Pulse – 80 bpm
Respiratory rate – 56 bpm
Physical Examination – left side
Rumen
Normal stratification
Pings
No pings
Lymph Nodes
prefemoral – normal
prescapular – normal
Lung auscultation
Difficult to auscult
Honking on inspiration
Open mouth breathing
Heart auscultation
Rhythm - regular
Intensity - normal
Sounds – no murmurs or
arrhythmias
Jugular vein
Normal
Cervical skin tent
< 2 seconds
Physical Examination – right side
Pings
No pings
Seccussion
No fluid sloshing
Ballotment
normal
Lymph nodes
Prefemoral – normal
Prescapular - normal
Lung auscultation
Difficult to auscult
Honking on inspiration
Open mouth breathing
Heart auscultation
Rhythm – regular
Intensity – normal
Sounds – no murmurs or
arrhythmias
Jugular vein
Normal
Cervical skin tent
< 2 seconds
Physical Examination
Abdominal pain
None present
Skin
normal
Extremities
normal
Musculoskeletal
normal
Head
Ocular discharge - none
Eye examination – mild scleral
injection
Nasal discharge –
whitish/yellow, fetid
Mucous membrane color - pale
Mouth
Teeth – normal
Hypersalivation
Neck – large, painful larynx
Physical Examination
Mammary gland
Rectal palpation
Inflammation
NA
Strip cup
NA
California mastitis test
NA
NA
Feces
normal
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
– Save money for
treatment
Antibiotics
– Florfenicol
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
Body condition score 5/9
Gant
Behavior
Depressed
Gait and posture
Head and neck extended
Urine analysis
None caught
TPR
Temperature – 105.4 ºF
Pulse – 76 bpm
Respiratory rate – 54 bpm
Physical Examination – left side
Rumen
Normal stratification
Pings
No pings
Lymph Nodes
prefemoral – normal
prescapular - normal
Lung auscultation
Loud and harsh
Crackles and wheezes
Rapid, shallow breaths
Heart auscultation
Rhythm - regular
Intensity - normal
Sounds – no murmurs or
arrhythmias
Jugular vein
Normal
Cervical skin tent
4 seconds
Physical Examination – right side
Pings
No pings
Seccussion
No fluid sloshing
Ballotment
normal
Lymph nodes
Prefemoral – normal
Prescapular - normal
Lung auscultation
Loud and harsh
Crackles and wheezes
Rapid, shallow breaths
Heart auscultation
Rhythm – regular
Intensity – normal
Sounds – no murmurs or
arrhythmias
Jugular vein
Normal
Cervical skin tent
4 seconds
Physical Examination
Abdominal pain
None present
Skin
normal
Extremities
normal
Musculoskeletal
normal
Head
Ocular discharge - mucopurulent
Eye examination - normal
Nasal discharge - mucopurulent
Mucous membrane color - pale
Teeth - normal
Physical Examination
Mammary gland
Inflammation
NA
Strip cup
NA
California mastitis test
NA
Rectal palpation
NA
Feces
normal
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
treatment
Antibiotics and
Anti inflammatory
– Resflor gold
Florfenicol
– 40 mg/kg
Flunixin meglumine
– 2.2 mg/kg IV
Arterial blood gas
CBC
Radiographs
Dosed at 6ml/100 lbs
SQ
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
Body condition score 3/5
Behavior
QAR
Gait and posture
Slight arch to back
Urine analysis
None caught
TPR
Temperature – 102.5 ºF
Pulse – 92 bpm
Respiratory rate – 32 bpm
Physical Examination – left side
Rumen
Decreased fill
Pings
No pings
Lymph Nodes
prefemoral – normal
prescapular – sl.
enlarged
Lung auscultation
normal breath sounds
Heart auscultation
Rhythm - UTD
Intensity - UTD
Sounds – abnormal
Jugular vein
Distended with pulses
Cervical skin tent
5 seconds
Physical Examination – right side
Pings
No pings
Seccussion
No fluid sloshing
Ballotment
normal
Lymph nodes
Prefemoral – normal
Prescapular – sl.
enlargement
Lung auscultation
Normal breath sounds
Heart auscultation
Rhythm – UTD
Intensity – UTD
Sounds – abnormal
Jugular vein
Distended with pulses
Cervical skin tent
5 seconds
Physical Examination
Abdominal pain
Elbows abducted
Skin
normal
Extremities
normal
Musculoskeletal
normal
Head
Ocular discharge - none
Eye examination - normal
Nasal discharge - none
Mucous membrane color - pink
Teeth - normal
Venous Distention
Jugular Pulses
Cardiac Auscultation new
Venous Pulsation
Physical Examination
Mammary gland
Rectal palpation
Inflammation
NA
Strip cup
NA
California mastitis test
NA
weak aortic pulse
Feces
normal
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
owner
Echocardiogram ????
CBC
BLV serology/PCR
– Cancer hunt
Euthanasia
Septic Pericarditis