{"id":1435,"date":"2012-09-01T19:57:08","date_gmt":"2012-09-01T19:57:08","guid":{"rendered":"http:\/\/phosdev.com\/todaysveterinarypractice\/?p=1435"},"modified":"2022-02-18T17:18:09","modified_gmt":"2022-02-18T17:18:09","slug":"internal-medicine-practice-pearls","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/internal-medicine\/internal-medicine-practice-pearls\/","title":{"rendered":"Internal Medicine Practice Pearls"},"content":{"rendered":"<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2016\/06\/T1209F04.pdf\"><img decoding=\"async\" class=\"alignnone size-full wp-image-9886\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2011\/07\/pdf_button.png\" alt=\"pdf_button\" width=\"110\" height=\"27\" \/><\/a><\/p>\n<hr \/>\n<p><em>Michael Schaer, DVM, Diplomate ACVIM &amp; ACVECC<\/em><\/p>\n<h2>THE ART OF DIAGNOSIS<\/h2>\n<ul>\n<li><em>To make the correct diagnosis, we need the right choices.<br \/>\n<\/em><\/li>\n<li><em>To consider the right choices, we need the right information.<br \/>\n<\/em><\/li>\n<li><em>To obtain the right information, we need to ask the right questions.<br \/>\n<\/em><\/li>\n<li><em>Asking the right questions is the hallmark of clinical expertise.<br \/>\n<\/em><\/li>\n<\/ul>\n<p><em>~ R. Kreisburg, MD<\/em><\/p>\n<p>After 25 years of practice, most clinicians come to the conclusion that the practice of medicine is both an art and a science. The main objective of this article is to share some of the lessons I have learned over the years, with the hope that this knowledge will benefit the readers&#8217; patients.<\/p>\n<p>For the sake of simplicity, thoughts have been categorized according to:<\/p>\n<ul>\n<li>Patient evaluation and care<\/li>\n<li>Fluid administration and medications<\/li>\n<li>Diseases by organ system.<\/li>\n<\/ul>\n<div class=\"orange-box\">\n<h2 class=\"bluboldheader\">GENERAL CLINICAL SIGNS<\/h2>\n<p><strong><span class=\"GrAquaBoldHeader\">Fluid Accumulation: Chest and Abdomen\u00a0<\/span><\/strong><br \/>\nCommonly indicates a serious disease, such as neoplasia, heart failure, diffuse inflammation, or hypoproteinemia<\/p>\n<p><strong><span class=\"GrAquaBoldHeader\">High Temperature<\/span><\/strong><br \/>\nTemperature &gt; 109.4\u00b0F = heat stroke; beware of disseminated intravascular coagulation<\/p>\n<ul>\n<li><em>Fever + immune-mediated disease =\u00a0<\/em>appetite can persist<em><br \/>\n<\/em><\/li>\n<li><em>Fever + sepsis =\u00a0<\/em>anorexia<\/li>\n<\/ul>\n<p><strong><span class=\"GrAquaBoldHeader\">Hyperventilation<\/span><\/strong><br \/>\nVarious causes include cardiorespiratory distress, pyrexia, brain disease, Cushing&#8217;s disease, metabolic acidosis, anxiety, pain, shock, and anemia.<\/p>\n<p><strong><span class=\"GrAquaBoldHeader\">Pallor &amp; Icterus<\/span><\/strong><br \/>\nPallor can be caused by hypoxia, shock, anemia, or peripheral vasoconstriction.<\/p>\n<ul>\n<li><em>Anemic pallor + icterus =\u00a0<\/em>yellow mucous membrane color<em><br \/>\n<\/em><\/li>\n<li><em>Pink mucous membranes + icterus =\u00a0<\/em>orange mucous membrane color<\/li>\n<\/ul>\n<p><strong><span class=\"GrAquaBoldHeader\">Septic Shock<\/span><\/strong><br \/>\nPatient typically has hypothermia, thrombocytopenia, and hypotension refractory to intravenous fluid treatment.<\/p>\n<\/div>\n<p>&nbsp;<\/p>\n<table style=\"font-family: sans-serif;color: black\" border=\"1\" width=\"100%\" cellpadding=\"5\">\n<tbody>\n<tr bgcolor=\"#ffffff\">\n<td class=\"white\">\n<h2><span style=\"color: #000000\"><strong>Patient Evaluation &amp; Management<\/strong><\/span><\/h2>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"font-family: sans-serif;color: black\" border=\"1\" width=\"100%\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"bluboldheader\" colspan=\"2\" align=\"center\" valign=\"top\">\n<p><span style=\"color: #000000\"><strong>PATIENT EVALUATION<\/strong><\/span><\/p>\n<p>&nbsp;<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">History<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 It is all in the history.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Physical Examination<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Skin turgor is difficult to assess with cachexia and obesity.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Look under the tongue for a linear foreign body in any vomiting cat or dog.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Palpation: &#8220;Touch but don&#8217;t squeeze the Charmin.&#8221;<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Have you been palpating each mammary gland for early detection of mammary tumors?<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 If something &#8220;just ain&#8217;t right,&#8221; consider neurologic disorders.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 To detect early signs of weakness, look at the rear limbs for splaying or crossing.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Circumlinear ulcer in frenulum: Consider linear foreign body.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Sudden mental depression 2 to 3 days post enterotomy: Rule out dehiscence and sepsis.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Diagnostics<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">The big 6 preliminary tests for assessing ill animals when client funds are limited:<\/span><br \/>\n<span style=\"color: #000000\"> 1. Packed cell volume<\/span><br \/>\n<span style=\"color: #000000\"> 2. Total protein<\/span><br \/>\n<span style=\"color: #000000\"> 3. Blood urea nitrogen<\/span><br \/>\n<span style=\"color: #000000\"> 4. Glucose<\/span><br \/>\n<span style=\"color: #000000\"> 5. Urinalysis<\/span><br \/>\n<span style=\"color: #000000\"> 6. Chest\/abdominal radiographs<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Imaging<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Every sick or trauma patient should have chest and abdominal radiographs performed on initial evaluation.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Performing abdominal ultrasound without abdominal radiographs will eventually lead to missed information.<\/span><\/p>\n<p class=\"blue\"><span style=\"color: #000000\">See Small Animal Thoracic Imaging, September\/October 2011, and Small Animal Abdominal Imaging, November\/December 2011, available at todaysveterinarypractice.com.<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Advanced Diagnostics<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Don&#8217;t just look at a lump\u2014stick it! A lump is a lump until you do so.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Traumatic ear flush can cause inner ear and vestibular disease.<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"font-family: sans-serif;color: black\" border=\"1\" width=\"100%\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"bluboldheader\" colspan=\"2\" align=\"center\" valign=\"top\"><span style=\"color: #000000\"><span style=\"color: #000000\"><strong>PATIENT MANAGEMENT<\/strong><\/span><\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Feline<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 A clean cat is a happy cat.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Cats hate atropine eye drops, which cause marked salivation; use ointment instead.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Do not forget to evaluate cats for thiamine deficiency.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Body bandages in cats cause pseudoparalysis.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Pediatrics<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Don&#8217;t forget glucose for neonates.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 A heparinized syringe may contain as much as 200 U heparin\u2014too much for puppies and kittens (best not to exceed 150 U or 0.15 U\/g).<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Sedation<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Senior dogs and cats poorly tolerate tranquilization.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Avoid sedating acutely ill patients unless absolutely necessary.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Don&#8217;t sedate at the end of the day unless IV fluid support is provided, especially in senior patients; it is an invitation for renal failure.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">Therapeutics<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">\u2022 After therapeutic paracentesis, repeat abdominal palpation so you do not pass the mass.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Rapid abdominocentesis is effective and safe for chronic ascites, except when ascites is caused by chronic liver disease; in these cases simultaneous IV plasma or albumin infusion is recommended.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 A heat lamp and rubbing alcohol can ignite the patient.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">Digestive System<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">\u2022 Postoperative patients or those with pelvic fractures will appreciate glycerine suppositories.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 No Fleet enemas (fleetlabs.com) for obstipation, unless you want to treat a case of hypocalcemia.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">Urinary System<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">\u2022 Manually expressing a male dog&#8217;s bladder may result in rupture.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Some pathologic bladders can leak after cystocentesis.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Ketamine (3 mg IV) can adequately restrain an ill cat with urethral obstruction.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">End-of-Life Considerations<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">\u2022 Many terminal patients will show a burst of movement prior to dying.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Never euthanize based on cytology results because cytologic errors may be as high as 50%.<\/span><\/td>\n<\/tr>\n<tr>\n<td class=\"references\" colspan=\"2\" valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">SC = subcutaneous; IM = intramuscular; IV = intravenous; U = units<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"font-family: sans-serif;color: black\" border=\"1\" width=\"100%\" cellpadding=\"5\">\n<tbody>\n<tr bgcolor=\"#fffff0\">\n<td class=\"white\" bgcolor=\"#ffffff\">\n<h2><span style=\"color: #000000\"><span style=\"color: #000000\"><strong>Fluid Administration &amp; Medications<\/strong><\/span><\/span><\/h2>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"font-family: sans-serif;color: black\" border=\"1\" width=\"100%\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"font_purple\" colspan=\"2\" align=\"center\" valign=\"top\"><span style=\"color: #000000\"><span style=\"color: #000000\"><strong>FLUID &amp; ELECTROLYTES<\/strong><\/span><\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Administration<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 If the patient is eating and drinking without excess fluid loss, IV fluids are not needed.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 SC fluid administration: Isotonic, 18-gauge needle, gravity flow without positive pressure; 50 mL\/site in adult cats<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Volume load with isotonic crystalloid.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Rehydrate before inducing diuresis; however, check urine specific gravity first.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Intraosseous cannulas can be life saving.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Specific Recommendations<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\">\n<p><span style=\"color: #000000\">\u2022 All IV maintenance fluids should contain KCl (7\u201310 mEq\/250 mL); exceptions are cases of oliguria and untreated Addison&#8217;s disease.<\/span><\/p>\n<p><span style=\"color: #000000\">\u2022 To make 2.5% dextrose solution increments, add:<\/span><br \/>\n<span style=\"color: #000000\"> D-50-W (12.5 mL) to fluids (LRS, NaCl; 250 mL) or<\/span><br \/>\n<span style=\"color: #000000\"> D-50-W (50 mL) to isotonic crystalloid (1 L).<\/span><\/p>\n<p><span style=\"color: #000000\">\u2022 Adult cats:<\/span><br \/>\n<span style=\"color: #000000\"> When IV administration is not an option, manage hypocalcemia by adding 10% calcium gluconate (2.5 mL\/kg) to 0.9% NaCl (150 mL); administer SC Q 12 H<\/span><br \/>\n<span style=\"color: #000000\"> Avoid hypokalemia when administering SC fluids by adding KCl (7 mEq) to LRS (250 mL)<\/span><\/p>\n<p class=\"blue\"><span style=\"color: #000000\">See Resuscitative Fluid Therapy for Circulatory Shock, September\/October 2011, available at todaysveterinarypractice.com.<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Physiologic Conditions<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Metabolic alkalosis (usually with hypokalemia) = TCO2 &gt; 40 mEq\/L<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Severe metabolic acidosis = TCO2 &lt; 10 mEq\/L (usually)<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Cautions<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Be careful with SC fluids: Dogs are not cats; they are prone to sloughing.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Potassium penicillin contains 1.7 mEq K+\/million U; take heed when bolusing.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Avoid tissue edema by restricting excess fluids in cases of severe pulmonary, brain, and general trauma.<\/span><\/td>\n<\/tr>\n<tr>\n<td class=\"references\" colspan=\"2\" valign=\"top\" bgcolor=\"#f7f3f8\"><span style=\"color: #000000\">D-50-W = dextrose in water (50%); GI = gastrointestinal; IV = intravenous; KCl = potassium chloride; LRS = lactated Ringer&#8217;s solution; NaCl = sodium chloride; SC = subcutaneous; TCO2 = total carbon dioxide; U = units<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"font-family: sans-serif;color: black\" border=\"1\" width=\"100%\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"font_purple\" colspan=\"2\" align=\"center\" valign=\"top\"><span style=\"color: #000000\"><span style=\"color: #000000\"><strong>MEDICATIONS<\/strong><\/span><\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Specific Recommendations<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Aminoglycosides should only be administered after rehydration.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Doxycycline &amp; clindamycin tablet administration should be followed by a syringe of water to encourage swallowing and prevent esophageal stricture in cats.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Imipenem should be considered for life threatening infections.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Prednisone will arrest the progression of craniomandibular osteopathy if caught early; extended treatment with alternate day therapy will reverse early changes and impede disease progression.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Adverse Effects<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Consider adverse drug effects when unexpected signs appear following treatment with a new medication.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Prevent anaphylactoid reactions by avoiding IV administration of:<\/span><br \/>\n<span style=\"color: #000000\"> Thiamine (administer IM)<\/span><br \/>\n<span style=\"color: #000000\"> Vitamin K1 (administer SC)<\/span><br \/>\n<span style=\"color: #000000\"> Vitamin B1 (administer SC)<\/span><br \/>\n<span style=\"color: #000000\"> Vitamin preparations<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Panmycin (oral tetracycline) can cause fever in cats.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">Interactions<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">\u2022 Theophylline &amp; ciprofloxacin: Use together will result in theophylline overdose.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Cimetidine &amp; metronidazole: Cimetidine, a cytochrome P450 inhibitor, enhances metronidazole-induced neurotoxicity.<\/span><\/td>\n<\/tr>\n<tr>\n<td class=\"references\" colspan=\"2\" valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">SC = subcutaneous; IM = intramuscular; IV = intravenous<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"font-family: sans-serif;color: black\" border=\"1\" width=\"100%\" cellpadding=\"5\">\n<tbody>\n<tr bgcolor=\"#ffffff\">\n<td class=\"white\" bgcolor=\"#ffffff\">\n<h2><span style=\"color: #000000\"><span style=\"color: #000000\"><strong>Disease by Organ System<\/strong><\/span><\/span><\/h2>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"font-family: sans-serif;color: black\" border=\"1\" width=\"100%\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"GrAquaBoldHeader\" colspan=\"2\" align=\"center\" valign=\"top\"><span style=\"color: #000000\"><span style=\"color: #000000\"><strong>CARDIORESPIRATORY DISEASE<\/strong><\/span><\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Clinical Signs &amp; Disease Identification<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Watch for the exaggerated abdominal component of respiration.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Cardiac arrhythmias: Consider digoxin intoxication<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Cough in cats: Consider allergic bronchitis, tracheobronchial disorders, flukes, lung worms, heartworms, hair or foreign body in trachea, tumors<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Diffuse muffling: Usually caused by chest fluid<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Dorsal muffling: Caused by air or mass in chest<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Lack of coughing in dyspneic cats: Usually indicates heart disease<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Muffled chest sounds: Causes include fluid, air, or mass in chest; obesity; deep-chested conformation; and even the clinician&#8217;s plugged ears<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Many patients die without ever showing open-mouth breathing.<\/span><\/p>\n<p class=\"blue\"><span style=\"color: #000000\">See Feline Rhinitis &amp; Upper Respiratory Disease, July\/August 2012, available at todaysveterinarypractice.com.<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Diagnostics<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Electrocardiography:<\/span><br \/>\n<span style=\"color: #000000\"> Cardiomegaly does not always cause tall ECG complexes.<\/span><br \/>\n<span style=\"color: #000000\"> A standing lead 2 ECG is satisfactory for rate, rhythm, and interval measurements.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Echocardiography: Can be used to diagnose vegetative endocarditis<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Imaging:<\/span><br \/>\n<span style=\"color: #000000\"> For dyspneic patients, keep the unaffected side &#8220;up&#8221; (away from the table) when taking radiographs.<\/span><br \/>\n<span style=\"color: #000000\"> Ketamine (3\u20135 mg IV, total dose) can allow &#8220;survival&#8221; radiographs in a dyspneic cat.<\/span><br \/>\n<span style=\"color: #000000\"> Minimal radiographic infiltrates: Consider bacterial pneumonia + leukopenia (myelosuppression)<\/span><br \/>\n<span style=\"color: #000000\"> Sudden-onset diffuse pulmonary infiltrates: Consider ARDS<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Therapeutics<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Dispense prednisone and furosemide for the earliest signs of pulmonary thromboembolism in dogs treated for heartworms.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 H2-blockers alter stomach microbial population, which worsens aspiration pneumonia.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Do not use beta blockers until pulmonary edema resolves.<\/span><\/td>\n<\/tr>\n<tr>\n<td class=\"references\" colspan=\"2\" valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">ARDS = acute respiratory distress syndrome; ECG = electrocardiography<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"font-family: sans-serif;color: black\" border=\"1\" width=\"100%\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"GrAquaBoldHeader\" colspan=\"2\" align=\"center\" valign=\"top\"><span style=\"color: #000000\"><span style=\"color: #000000\"><strong>NEOPLASIA<\/strong><\/span><\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Clinical Signs &amp; Disease Identification<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Bloody, suppurative, mucoid nasal discharge: Produced by nasal cancer<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Copious mucoid nasal discharge: Consider nasal adenocarcinoma.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Firm mammary nodule: Assume carcinoma until proven otherwise.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Massive generalized lymphadenopathy: Usually indicates lymphoma.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Cutaneous mast cell tumors can mimic any type of skin growth.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Don&#8217;t miss lymphangitic inflammatory mammary carcinoma.<\/span><\/p>\n<p class=\"blue\"><span style=\"color: #000000\">See What&#8217;s New in Lymphoma: Cats &amp; Dogs, November\/December 2011, available at todaysveterinarypractice.com.<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Diagnostics<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Cancer can cause elevated total WBC count and fever.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Mammary tumors: Don&#8217;t stick them; remove them.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Try gastric biopsy forceps for nasal biopsy.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Closed-mouth nasal cavity radiographs are useless.<\/span><\/td>\n<\/tr>\n<tr>\n<td class=\"references\" colspan=\"2\" valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">WBC = white blood cell<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"font-family: sans-serif;color: black\" border=\"1\" width=\"100%\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"GrAquaBoldHeader\" colspan=\"2\" align=\"center\" valign=\"top\"><span style=\"color: #000000\"><span style=\"color: #000000\"><strong>ENDOCRINE DISEASE<\/strong><\/span><\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">General<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 The hypocalcemic cat may not exhibit early signs of tetany; it may simply be dazed and weak.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Keep an eye out for the atypical Addisonian patient.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Diagnostics<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Blood glucose meters: Not very accurate at the high\/low ends of scale<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Tears: May help detect hyperglycemia<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Soiled litter: Can be used to detect glycosuria<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Assess toy\/miniature breed dogs with eclampsia for hypoglycemia.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">Laboratory Analysis<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">\u2022 Glycosuria: Can occur with diabetes, Fanconi&#8217;s syndrome, proximal renal tubular disease, stress, and IV dextrose<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Hypercholesterolemia + elevated CK: Can occur with hypothyroidism<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Hypocholesterolemia: Can occur in some patients with Addison&#8217;s disease<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Marked hyperglycemia: Present in oliguric diabetics<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Marked hyperglycemia + minimal glycosuria: Consider oliguria\/anuria<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Morning marked glycosuria + afternoon diminished glycosuria: Typifies transient insulin response (requires split dose)<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Therapeutics<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 U-100 syringe (or TB syringe) must be used for U-100 insulin.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 When treating diabetic ketoacidosis, do not forget adequate K+.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 If patient initially hypokalemic, delay insulin for several hours, but begin crystalloid supplemented with potassium.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 During the correction of hypokalemia, IV fluids alone can lower blood glucose by as much as 50% to 60%.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 For severe hypoglycemic encephalopathy, try mannitol.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 When fludrocortisone (Florinef, pfizer.com\/kingpharmaceuticals) is not effective, use DOCP (Percorten-V, norvartis.us) and prednisone.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 If you have a dog with Cushing&#8217;s disease and diabetes that becomes weak and depressed and is receiving both insulin and opDDD, remember:<\/span><br \/>\n<span style=\"color: #000000\"> If dog is opDDD toxic, its appetite will be absent that day and vomiting may have occurred.<\/span><br \/>\n<span style=\"color: #000000\"> If dog has been overdosed with insulin, it very likely will have eaten that morning; coma and seizures may be present.<\/span><br \/>\n<span style=\"color: #000000\"> If dog has both hypoglycemia and opDDD toxicity, any combination of the above can occur. In this situation, treat for the treatable if laboratory tests are unavailable, which would indicate dextrose and glucocorticoid administration.<\/span><\/p>\n<p class=\"blue\"><span style=\"color: #000000\">See Fundamentals for Insulin Therapy, September\/October 2011, available at todaysveterinarypractice.com.<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td class=\"references\" colspan=\"2\" valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">CK = creatine kinase; DOCP = desoxycorticosterone; IV = intravenous; K+ = potassium ion;<\/span><br \/>\n<span style=\"color: #000000\"> opDDD = 1,1-dichloro-2-(o-chlorophenyl)-2-(p-chlorophenyl) ethane; TB = tuberculin<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"font-family: sans-serif;color: black\" border=\"1\" width=\"100%\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"GrAquaBoldHeader\" colspan=\"2\" align=\"center\" valign=\"top\"><span style=\"color: #000000\"><span style=\"color: #000000\"><strong>TOXICITIES<\/strong><\/span><\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Clinical Signs &amp; Disease Identification<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Newly acquired bleeding: Consider anticoagulant rodenticide intoxication.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Sudden facial hemorrhagic lymphedema, hemorrhagic oral mucosa, subdued mentation: Consider Eastern diamondback rattlesnake envenomation.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Diagnostics<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 If identified early, ethylene glycol in urine sometimes fluoresces under a Wood&#8217;s lamp.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Unexplainable radiodense particles in bowel: Consider lead.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Therapeutics<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 DMSA: An oral chelator for lead poisoning<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 4-methylpyrazole: Use for antifreeze intoxication; avoids grogginess (currently unavailable).<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Vodka does work for ethylene glycol intoxication when ethanol is unavailable.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Oral vitamin K1 (4\u20136 weeks): Use for newer anticoagulant rodenticides<\/span><\/p>\n<p class=\"blue\"><span style=\"color: #000000\">See Rodenticide Poisoning: What to Do After Exposure, March\/April 2012, available at todaysveterinarypractice.com.<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td class=\"references\" colspan=\"2\" valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">CK = creatine kinase; DOCP = desoxycorticosterone; IV = intravenous; K+ = potassium ion;<\/span><br \/>\n<span style=\"color: #000000\"> opDDD = 1,1-dichloro-2-(o-chlorophenyl)-2-(p-chlorophenyl) ethane; TB = tuberculin<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"font-family: sans-serif;color: black\" border=\"1\" width=\"100%\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"GrAquaBoldHeader\" colspan=\"2\" align=\"center\" valign=\"top\"><span style=\"color: #000000\"><span style=\"color: #000000\"><strong>GASTROINTESTINAL DISEASE<\/strong><\/span><\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Clinical Signs &amp; Disease Identification<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Acute excruciating abdominal pain: Consider bowel infarction or intestinal volvulus.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Bile in vomitus: Signifies pyloric patency<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Black stools: Consider upper GI bleed, thrombocytopenia, blood in mouth, bismuth subsalicylate (&#8220;Pepto&#8221;), or iron or charcoal ingestion.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Co-existing vomiting\/diarrhea: Rarely associated with GI obstructions<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Coffee ground vomitus: Consider gastric ulcers (primary\/secondary) or uremic gastritis.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Melena: Consider upper GI lesions or thrombocytopenia.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Occult blood loss: Consider GI disease, especially if accompanied by hypoproteinemia and anemia.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Vomiting: Main sign of GI obstruction; the lower the obstruction, the more feculent the vomitus<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Diagnostics<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Physical examination:<\/span><br \/>\n<span style=\"color: #000000\"> Melena detection: &#8220;Let your finger do the walking&#8221;<br \/>\n<\/span>\u2022 Laboratory analysis:<br \/>\nBilirubinuria in cats: Signifies liver disease<br \/>\nElevated BUN + normal creatinine: Consider upper GI<br \/>\nbleed, especially if kidney can concentrate urine<br \/>\nMetabolic alkalosis + hypokalemia: Common with upper GI obstructions<br \/>\n\u2022 Imaging:<br \/>\nRight kidney easily visible on radiograph: Consider acute pancreatitis (<strong>Figure 1<\/strong>).<br \/>\nCholangiostasis: Consider sepsis.<br \/>\nDiffuse inflammatory bowel disease: Can often be diagnosed with distal colon biopsy<br \/>\nGas in the gall bladder is a surgical emergency.<\/p>\n<p><div id=\"attachment_4495\" style=\"width: 161px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-3.56.24-PM.png\"><img decoding=\"async\" aria-describedby=\"caption-attachment-4495\" class=\"wp-image-4495\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-3.56.24-PM.png\" alt=\"Screen Shot 2015-06-16 at 3.56.24 PM\" width=\"151\" height=\"212\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-3.56.24-PM.png 244w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-3.56.24-PM-213x300.png 213w\" sizes=\"(max-width: 151px) 100vw, 151px\" \/><\/a><p id=\"caption-attachment-4495\" class=\"wp-caption-text\">Figure 1. Ventraldorsal abdominal radiograph of a dog with acute pancreatitis; note the visibility of the right kidney<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Therapeutics<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 0.9% NaCl + KCl is best for upper GI obstructions.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Never let the sun set on a linear foreign body intestinal obstruction.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 J-tube feeding: Beneficial for the prolonged period of NPO in patients with pancreatitis<\/span><\/td>\n<\/tr>\n<tr>\n<td class=\"references\" colspan=\"2\" valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">BUN = blood urea nitrogen; GI = gastrointestinal; KCl = potassium chloride; NaCl = sodium chloride; NPO = nil per os (no oral food or fluids)<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"font-family: sans-serif;color: black\" border=\"1\" width=\"100%\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"GrAquaBoldHeader\" colspan=\"2\" align=\"center\" valign=\"top\"><span style=\"color: #000000\"><span style=\"color: #000000\"><strong>HEMATOLOGIC DISEASE<\/strong><\/span><\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Clinical Signs &amp; Disease Identification<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Newly acquired bleeding: Consider anticoagulant rodenticide intoxication<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Lumbosacral petechia (&#8220;lots of it&#8221;): Consider fleas + thrombocytopenia<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Pale petechia: Consider thrombocytopenia + anemia<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Bone marrow derived leukopenic animals don&#8217;t produce pus.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Diagnostics<\/span><\/p>\n<div class=\"wp-caption-dd\"><\/div>\n<p><em>\u00a0<\/em><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Blood Analysis:<\/span><br \/>\n<span style=\"color: #000000\"> Unclotted blood in clot tube: Consider coagulopathy.<\/span><br \/>\n<span style=\"color: #000000\"> Low WBCs, low RBCs, low platelets: Rule out bone marrow suppression.<\/span><br \/>\n<span style=\"color: #000000\"> Fulminant hemolysis: Results in anemia, hemoglobinemia, hemoglobinuria, weakness, depression, +\/- vomiting; then icterus<\/span><br \/>\n<span style=\"color: #000000\"> Observe for autoagglutination and spherocytes in IMHA.<\/span><br \/>\n<span style=\"color: #000000\"> A normal bleeding time assures that there is adequate platelet hemostasis; a normal platelet count does not.<\/span>\u2022 Imaging:<br \/>\nMassive splenomegaly (<strong>Figure 2<\/strong>): Consider splenic torsion, hypersplenism, lymphoma, and myeloproliferative or mast cell splenic neoplastic infiltrate.\u2022 Owners can use urine dipsticks to detect hemeprotein, an early sign of recurrent hemolysis.<\/p>\n<div id=\"attachment_4496\" style=\"width: 155px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-3.56.32-PM.png\"><img decoding=\"async\" aria-describedby=\"caption-attachment-4496\" class=\"wp-image-4496\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-3.56.32-PM.png\" alt=\"Screen Shot 2015-06-16 at 3.56.32 PM\" width=\"145\" height=\"93\" \/><\/a><p id=\"caption-attachment-4496\" class=\"wp-caption-text\">Figure 2. Radiograph (A) and surgical specimen (B) depicting splenomegaly caused by splenic torsion<\/p><\/div>\n<p><em><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-4494\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-3.56.39-PM.png\" alt=\"Screen Shot 2015-06-16 at 3.56.39 PM\" width=\"146\" height=\"98\" \/><\/em><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\"><span style=\"color: #000000\">Therapeutics<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Keep IMHA and ITP patients on maintenance prednisone (Q 2 D) for 9 to 12 months to avoid relapse.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Try danazol, azathioprine, or cyclosporine with prednisone for refractory IMHA and ITP.<\/span><\/td>\n<\/tr>\n<tr>\n<td class=\"references\" colspan=\"2\" valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">IMHA = immune-mediated hemolytic anemia; ITP = idiopathic thrombocytopenic purpura; RBC = red blood cell; WBC = white blood cell<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"font-family: sans-serif;color: black\" border=\"1\" width=\"100%\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"GrAquaBoldHeader\" colspan=\"2\" align=\"center\" valign=\"top\"><span style=\"color: #000000\"><span style=\"color: #000000\"><strong>NEUROLOGIC DISEASE<\/strong><\/span><\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"100\">Clinical Signs &amp; Disease Identification<\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Rapid onset LMN paralysis: Consider tick-borne disease, organophosphate or metronidazole toxicity, botulism, polyradiculoneuropathy, and coral snake bite.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Dilated pupils and blank stare (cats) (<strong>Figure 3<\/strong>): Consider thiamine deficiency.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Ventral cervical flexion with fixed dilated pupils: Consider thiamine deficiency.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Coma: Consider diffuse cerebral and brainstem damage, metabolic abnormalities, and adverse drug effects.<\/span><\/p>\n<p><div id=\"attachment_4498\" style=\"width: 285px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-4.01.19-PM.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-4498\" class=\"wp-image-4498 size-full\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-4.01.19-PM.png\" alt=\"Screen Shot 2015-06-16 at 4.01.19 PM\" width=\"275\" height=\"173\" \/><\/a><p id=\"caption-attachment-4498\" class=\"wp-caption-text\">Figure 3. Cat with thiamine deficiency; note dilated pupils that are fixed and nonresponsive to light<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td class=\"references\" colspan=\"2\" valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">LMN = lower motor neuron<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"font-family: sans-serif;color: black\" border=\"1\" width=\"100%\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"GrAquaBoldHeader\" colspan=\"2\" align=\"center\" valign=\"top\"><span style=\"color: #000000\"><span style=\"color: #000000\"><strong>UROGENITAL DISEASE<\/strong><\/span><\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"150\"><span style=\"color: #000000\">Clinical Signs &amp; Disease Identification<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Cessation of PU in ill patient: Consider oliguria\/anuria, which are bad signs.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Hematuria without stranguria: Consider coagulopathy or primary renal bleed.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Ill, intact female: Rule out pyometra.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Murky urine: Can be caused by pus, chyle, crystals<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Nasal crustiness, scleral injection, &#8220;muddy&#8221; mucous membranes: May indicate uremia<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Passive penile bleed, normal urination, normal dog: Consider BPH.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Prostate inflammation &#8220;prostatic shuffle&#8221; (gait characterized by short shuffling steps)<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Stranguria accompanying hematuria: Consider recent renal bleed + clots in the bladder in addition to more common disorders, such as cystitis.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"150\">\n<p>Diagnostics<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-4.02.03-PM.png\">\u00a0<\/a><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\" width=\"460\"><span style=\"color: #000000\">\u2022 Physical Examination:<\/span><br \/>\n<span style=\"color: #000000\"> Prostate trends: Carcinoma\u2014asymmetrical, hard, mid- or<\/span><br \/>\n<span style=\"color: #000000\"> caudal pelvis; BPH\u2014symmetrical, firm, anterior displacement<\/span><br \/>\n<span style=\"color: #000000\"> Urethral pathology (female dog): Perform rectal examination<\/span><br \/>\n<span style=\"color: #000000\"> Scottish terriers have very large BPH.<br \/>\n<\/span>\u2022 Laboratory Analysis:<br \/>\nEmphysematous cystitis (<strong>Figure 4<\/strong>): Rule out diabetes mellitus.<\/p>\n<div id=\"attachment_4499\" style=\"width: 224px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-4.01.57-PM.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-4499\" class=\"wp-image-4499\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-4.01.57-PM.png\" alt=\"Screen Shot 2015-06-16 at 4.01.57 PM\" width=\"214\" height=\"120\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-4.01.57-PM.png 311w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-4.01.57-PM-300x168.png 300w\" sizes=\"(max-width: 214px) 100vw, 214px\" \/><\/a><p id=\"caption-attachment-4499\" class=\"wp-caption-text\">Figure 4. Lateral abdominal radiograph depicting emphysematous cystitis in a diabetic dog<\/p><\/div>\n<p>Hyperkalemia: Common in oliguric renal failure<br \/>\nNormo- or hypokalemia: Common in high-output chronic renal failure<br \/>\nPD + PU + isosthenuria: Consider chronic renal disease, even if normal BUN\/creatinine, but watch out for Cushing&#8217;s disease.<\/p>\n<p>\u2022 Imaging:<br \/>\nBilateral renomegaly (<strong>Figure 5<\/strong>) means very serious disease: Lymphoma, hydronephrosis, pyonephrosis, granuloma, inflammation, subcapsular edema, polycystic kidneys<br \/>\nCats with 1 big kidney + 1 small kidney: May equal 1 fibrotic kidney + 1 compensatory hypertrophic kidney that is also fibrotic<br \/>\nMale dog + stranguria: Examine immediately and radiograph to rule out obstructive uropathy<br \/>\n\u2022 Cystocentesis: Be careful with pyometra patients\u2014look before you stick<\/p>\n<div id=\"attachment_4501\" style=\"width: 173px\" class=\"wp-caption alignnone\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-4501\" class=\"wp-image-4501\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-4.02.07-PM.png\" alt=\"Screen Shot 2015-06-16 at 4.02.07 PM\" width=\"163\" height=\"102\" \/><p id=\"caption-attachment-4501\" class=\"wp-caption-text\">Figure 5. Abdominal radiographs of a cat with renal lymphosarcoma; note bilateral renomegaly (A and B)<\/p><\/div>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-4.02.03-PM.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-4500 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-4.02.03-PM-207x300.png\" alt=\"Screen Shot 2015-06-16 at 4.02.03 PM\" width=\"207\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-4.02.03-PM-207x300.png 207w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/Screen-Shot-2015-06-16-at-4.02.03-PM.png 221w\" sizes=\"(max-width: 207px) 100vw, 207px\" \/><\/a><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">Therapeutics<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">\u2022 Never let the sun set on a sick pyometra patient.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Empty urine line: Consider anuria, recent emptying, obstruction.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Fluid therapy: Always assess urine specific gravity first.<\/span><br \/>\n<span style=\"color: #000000\"> \u2022 Oliguria: Try administering dopamine (3\u20135 mcg\/kg\/min) before administering more fluids, furosemide, or mannitol.<\/span><\/td>\n<\/tr>\n<tr>\n<td class=\"references\" colspan=\"2\" valign=\"top\" bgcolor=\"#ffffff\"><span style=\"color: #000000\">BPH = benign prostatic hyperplasia; BUN = blood urea nitrogen; PD = polydipsia; PU = polyuria<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span class=\"author-bio\"><strong><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/f04_schaer.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-full wp-image-7333\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2012\/09\/f04_schaer.png\" alt=\"f04_schaer\" width=\"100\" height=\"119\" \/><\/a>Michael Schaer<\/strong>, DVM, Diplomate ACVIM &amp; ACVECC, is a professor emeritus with the University of Florida College of Veterinary Medicine, where he works with the emergency and critical care group. He is also an Editorial Advisory Board member for Today&#8217;s Veterinary Practice. His research interests include small animal internal medicine, endocrinology, and emergency\/critical care. Dr. Schaer has published numerous scientific articles and book chapters and is the author of Clinical Medicine of the Dog and Cat, 1st and 2nd editions, and Clinical Signs in Small Animal Medicine. He also lectures nationally and internationally. Prior to joining the UF faculty, he was in small animal private practice in New Jersey and on staff in the department of medicine at The Animal Medical Center in New York City. Dr. Schaer received his DVM from University of Illinois and completed his internship and residency at AMC.\u00a0<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Michael Schaer, DVM, Diplomate ACVIM &amp; ACVECC THE ART OF DIAGNOSIS To make the correct diagnosis, we need the right choices.<\/p>\n","protected":false},"author":1,"featured_media":2668,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":232,"footnotes":""},"categories":[382],"tags":[13],"class_list":["post-1435","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-september-october-2012","tag-peer-reviewed","column-features","clinical_topics-internal-medicine"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.7 (Yoast SEO v27.3) - 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