U penn case log lauren ritchey

University of Pennsylvania

Emergency Service and ICU

Externship Case LogLauren Ritchey

[email protected]

ICU

Patient 887022, ANAKEN, 10 year old, castrated

male Australian Shepherd

Presenting Complaint: Persistent anorexia, vomiting, and lethargy

Investigations Performed:

Blood biochemistry: Significantly elevated liver values and total bilirubin

CBC: Marked leukocytosis, neutrophilia, consistent with inflammatory response and/or infection. His platelets were mildly decreased.

PT/PTT: wnl

Abdomenocentesis and cytology: revealed exudative sample, with intracellular bacteria, and bile- consistent with a septic bile peritonitis

Abdominal US: Serial US’s revealed worsening of previously diagnosed severe acute pancreatitis, with associated inflammation and free fluid in his abdomen. Consistent with septic peritonitis. His biliary system was partially obstructed. His previously documented liver enlargement and decreased gastrointestinal motility were subjectively unchanged from previous.

Treatment:

Exploratory laparotomy with peritoneal lavage, and JP drain placement.

Patoprazole IV

Ondansetron IV

Maripotent IV

Metronidazole IV

Hetatarch and plasmalyte IV

Lidocaine CRI

Fentanyl CRI

Metoclopramide IV

Outcome:

Treated for 3 days in ICU, owners decided to humanely euthanize.

ANAKEN

Partial bile duct obstruction Pancreatitis

ICU Patient 849512, DEXTER, 8 year old, castrated

male, DSH Presenting Complaint: 12 hour history of lethargy and inappetence. Previously diagnosed with IBD.


COMPLETE BLOOD COUNT: The initial complete blood count revealed changes compatible with an acute onset of inflammation. When repeated, these changes were still present and were more severe. He also became anemic during his stay.

CHEMISTRY AND SERIAL FLEX PANELS: The initial chemistry panel showed elevation of his blood glucose, liver enzymes, and cholesterol as well as a decrease of his calcium, consistent with acute pancreatitis. Serial panels were repeated during his stay. His liver enzymes normalized but his blood glucose remained elevated. His phosphorus, magnesium, and albumin were transiently low but normalized.

TOTAL T4: was decreased, which ruled out a diagnosis of hyperthyroidism. His low thyroid level was likely secondary to his underlying disease.

URINALYSIS: Dexter's urine had a low concentration (1.018g/L) and contained glucose.

URINE CULTURE: negative, ruling out a diagnosis of a urinary tract infection.

CREATININE KINASE: elevated (3385U/L, normal 49-688), which can be caused by many etiologies including muscular damage, infectious and noninfectious myopathies, necrosis, anorexia and many others. Toxoplasma titers were submitted to rule out a common cause of increased CK in sick cats.

TOXOPLASMA TITERS: negative

BLOOD TYPE AND CROSSMATCH: Type A

ABDOMINAL ULTRASOUND: revealed a severe pancreatitis with accumulation of free fluid in the abdomen. There was also thickening of the wall of the common bile duct and thick bile in his gallbladder, which could have been caused by inflammation in the gallbladder and biliary tree. Dexter's kidneys were mildly enlarged and had chronic changes. His liver appeared brighter than normal on ultrasound, which had already been noted on his previous abdominal ultrasound. The appearance of his liver can be secondary to the administration of steroids (for his IBD) and/or some degree of accumulation of fat in the liver.

THORACIC RADIOGRAPHS: Thoracic radiographs were performed after Dexter developed increased respiratory efforts and rate. Changes observed on radiographs were compatible with pulmonary edema (accumulation of fluid in the lungs). This could have been due to the high volume of fluid needed to control his blood pressure and/or the presence of an underlying heart disease.

ABDOMINOCENTESIS AND FLUID ANALYSIS: The fluid was analyzed three times during his stay and there was no evidence of organisms (bacteria) or neoplasia. The accumulation of fluid in his abdomen was likely due to the inflammation around his pancreas leading to the leakage of fluid in the abdomen.

ESOPHAGOSTOMY TUBE PLACEMENT

ECHOCARDIOGRAM: showed moderate tricuspid regurgitation as well as an enlargement of his atrium. The enlargement of his atrium may have been secondary to the administration of fluids or was present prior to initiation of therapy for acute pancreatitis. The severity of the tricuspid regurgitation was also significantly worse than on the previous echocardiogram performed 2 years ago. It remains unclear whether this represents disease progression or exacerbation of regurgitation due to volume overload. No evidence of significant structural heart disease was identified echocardiographically.

Dexter Treatment:

IVF (stopped when pulmonary edema occurred)

Pantoprazole, Cerenia, Ondansetron

Previously rx chlorambucil, prednisolone, metronidazole

E-Tube feedings

Electrolyte supplementation (Ca, Mg)

O2

Ampicillin IV

Fentanyl CRI

Glargine insulin

Outcome: Diagnosed with pancreatitis, diabetes mellitus, and IBD. Stabilized in ICU, then went home with e-tube, and continued on medical treatments at home.

2012

Present

ICU Patient 887392, ROYAL, 6 month

old, male entire English Bulldog Presenting Complaint: presented through emergency service in respiratory distress. Vomited and aspirated 2 days previous.


RADIOGRAPHS: there was consolidation within the right middle, right cranial, and left cranial lung lobes that is most

consistent with potential aspiration pneumonia. His esophagus was segmentally dilated, most consistent with

aerophagia. Thoracic radiographs were repeated prior to discharge which showed large improvements in all lung

fields. Abdominal radiographs do not show any signs of mechanical obstruction causing his vomiting episodes. There is

no evidence of a static hiatal hernia, however this can occur as a dynamic process and may be displayed in X-rays.

EMERGENCY BLOODWORK: During his respiratory crisis, his blood work revealed a markedly increased carbon dioxide

level, consistent with a complete upper airway obstruction and hypoventilation. The lactate was elevated indicating

a temporary decrease in oxygen reaching his tissues. After intubation and manual ventilation, an arterial blood gas

revealed a correct carbon dioxide level but a poor oxygen level despite the level of oxygen being provided to him.

This indicates a likely lower airway disease process contributing to his respiratory distress.

EXTENDED BLOODWORK (CBC/Chem/Coagulation panel) His platelets and other coagulation values (PT and PTT)

were well within normal limits. CBC and Chemistry parameters were all within normal limits.

URINE CULTURE: A urine culture performed following removal of his urinary catheter was negative for bacterial growth.

ENDOTRACHEAL WASH: An endotracheal wash was performed which showed gram negative bacteria. Based off

these results, Royal was switched to an antibiotic susceptible to the bacterial grown.

SURGICAL PROCEDURES: Royal underwent a soft palate resection, laryngeal saccule removal, castration, temporary

tracheostomy, and enlargement of his previously stenotic nares. His upper airway had significant swelling and

inflammation. Post operatively, he remained intubated via the tracheostomy tube and on the ventilator.

Treatment and Outcome: Royal required emergency endotracheal intubation and ventilation to protect and manage an

open airway in order for him to breathe more comfortably. Upon intubation, his upper airway structures were identified as

causing a dynamic obstruction. He received gastroprotectants, anti-vomiting medications, antacids, and sedation. Royal

was transferred to the Intensive Care Unit for mechanical ventilation to maintain the tube in place and allow him to

oxygenate and ventilate normally. Upon transfer to the ICU, he remained on very low settings on the ventilator and

tolerated mechanical ventilation very well. He was brought to surgery and a temporary tracheostomy was placed to allow

for a good airway while his surgical sites were healing. He was gradually weaned off of the ventilator on 11/18/14 and his

tracheostomy tube was removed on 11/19/14. Royal was closely monitored and maintained on intravenous fluids and

medications for the remainder of his time in the ICU. He continued to improve throughout his stay and was switched to oral

medications prior to discharge. At the time of discharge he is eating and drinking normally with no episodes of

regurgitation. His breathing efforts and normal and he appears to be oxygenating appropriately.

ICU Patient 864200, BOGEY, 10 year old, castrated male

Yorkshire Terrier

Presenting Complaint: reassessment of progressive coughing and respiratory distress. Bogey has a history of lower airway disease with collapse, tracheal collapse, and pneumonia/tracheal infection. The tracheal collapse was treated with two tracheal stents in June 2013


Initial stabilization in oxygen cage and given 0.2 mg/kg butorphanol IM (IM).

COMPLETE BLOOD COUNT: Normal red blood cell and platelet counts. Total white blood cell count was normal except for mild monocytosis.

THORACIC RADIOGRAPHS (11/19): No change in his tracheal stents and resolved area that was concerning for pneumonia at his last visit (caudal aspect of left cranial lung lobe). There was an abnormal area of increased opacity in the left cranial lung lobe suggestive of local lung collapse, such as with a bronchial obstruction by mucous, or pneumonia.

TRACHEOSCOPY: A large amount of firm tissue was seen to be occluding 85-90% of Bogey's trachea. The abnormal tissue was growing in from the tracheal wall into the stent, in the intra-thoracic portion of this trachea near the end of his first stent. The tissue appeared most consistent excess tissue production following irritation & infection (granulation tissue) however a cancerous process within the trachea cannot be ruled out until biopsy results are available, which are pending.

TRACHEAL STENT PLACEMENT: Using fluoroscopic guidance and pre/post-operative tracheoscopy, a self expanding tracheal stent of the same size as his original stent (Infiniti Medical 14/10 x 61) was placed within Bogey's trachea, nested within the previously placed stents re-open his airway. The stent was able to completely compress the tissue along the wall of the trachea, restoring airway diameter, as confirmed via tracheoscopy.

THORACIC RADIOGRAPHS (11/22): Repeat radiographs showed increased whiteness in the right cranial and middle lung lobes, consistent with aspiration pneumonia (which is most likely due to aspiration of the bloody fluid from the biopsy/wash/re-stenting seen during his second tracheal scoping to confirm placement and opening of the airway.

ENDOTRACHEAL WASH: There were many inflammatory cells, but no bacteria were seen. Culture from this wash and tissue culture showed positive growth of Staphylococcus pseudointermedius, which is susceptible to both the Baytril and Clindamycin he has been receiving

Treatments:

IVF

intravenous antibiotics (Clindamycin & Baytril),

Cough tablets as needed

IV N-acetylcysteine

IV terbutaline

O2 supplementation

Outcome:

Recovered from stent placement in ICU for 3 days before being discharged and sent home on oral medication.

ICU Patient 866673, EDDIE, 11 year old, castrated male

Dachshund Presenting Complaints: Referral for elevated liver and kidney values and lethargy.


INITIAL BLOOD WORK/LAB WORK:

CBC - Eddie's initial complete blood count showed a mildly low platelet count with normal white blood cells and red blood cells.

Chemistry - Eddie's initial chemistry profile revealed high kidney values (BUN, creatinine, phosphorous), norma electrolytes, and elevated

liver values (ALP, AST, Bilirubin).

Urine culture - Eddie's urine culture here, and at his referring veterinarian, were negative. This makes urinary tract infection must less

likely.

Urinalysis (from referring veterinarian) - Eddie's urine was analyzed right before coming to Penn. He had small amounts of glucose and

protein in his urine, as well as inappropriately dilute urine, indicating a problem with the tubules of his kidney. Recheck in-house urine

samples here revealed that the glucose in his urine resolved.

Leptospirosis titers and PCR - Eddie's PCR and acute titers for leptospirosis, a disease that can cause liver and kidney damage, were

both negative. In order to confirm the absence of infection, convalescent titers were drawn on the day of his discharge. Convalescent

titers allow us to analyze the antibody response a few weeks after exposure, because it can take time for a true antibody response to be

mounted.

Coagulation profile - Due to Eddie's nose bleed and evidence of vasculitis (inflamed blood vessels) and history of Cushing's disease

(which can predispose animals to throwing blood clots), a coagulation profile was run. His initial coagulation profile revealed evidence

of increased blood clot formation and breakdown (elevated D-dimers). A repeat coagulation profile was drawn later in his

hospitalization when Eddie developed acute respiratory distress (in case he threw a clot to his lungs); at this time, his coagulation profile

was normal.

Abdominal US (serial)

Echocardiography (serial)

Lung fluid analysis

Thoracic radiographs

Diagnosis 1 (Confirmed) : Acute kidney injury, Chronic kidney disease, Hyperphosphatemia, Potential leptospirosis

Diagnosis 2 (Confirmed) : Degenerative valvular disease, acute heart failure (suspected chordae tendineae rupture), mechanical

ventilation, cough, exercise intolerance

Diagnosis 3 (Historical) : Cushing's disease, untreated

Diagnosis 4 (Confirmed) : Weight loss, progressive

Diagnosis 5 (Confirmed) : Elevated liver enzyme elevations, potentially doxycycline induced

Diagnosis 6 (Confirmed) : Urolithiasis (cystoliths, bilateral nephroliths)

Diagnosis 7 (Historical) : Intervertebral disc disease

Treatments:

Doxycycline

Lanthanum (Phosphorus binder)

Aluminum hydroxide (Phosphorus binder)

Cerenia

Denamarin (liver protectant)

Omeprazole

Mechanical ventilation, UCATH/UOP monitoring

Esophagostomy tube placement and feedings

Outcome:

ICU Patient 875310, GINGER, 12 year

old, spayed female Pomeranian Presenting complaint: Severe acute respiratory distress. Previously diagnosed with tracheal collapse, already received 2 stent

placement surgeries.

Investigations:

Stabilized in O2, given butorphanol IM.

Thoracic radiographs: unchanged stent position, no evidence of pneumonia or other lung tissue changes. Mild cardiomegaly noted.

Tracheoscopy: revealed almost completely obstructing collapse of the airway at the carina, and bronchi. Previously placed stents were still in place, and no aberrant granulation tissue or masses present around the stents.

Diagnoses:

Diagnosis 1 (Confirmed) : Progressive cervical tracheal collapse - 16 x 60 tracheal stent 2/5/2014

Diagnosis 2 (Confirmed) : Mainstem bronchial collapse

Diagnosis 3 (Historical) : Grade 2/6 left apical systolic heart murmur

Diagnosis 4 (Historical) : Perianal adenoma - completely excised 2/2014

Diagnosis 5 (Historical) : Diffuse tracheal collapse - 14/21 x 71 and 14 x 30 tracheal stents placed Oct 2013

Diagnosis 6 (Confirmed) : Bilateral medial patellar luxation

Treatment:

O2 supplementation

IV bronchodilators

Hydrocodone

Outcome: A 3rd stent could not be considered due to the location of the airway collapse. Humanely euthanized.

Ginger

ICU Patient 887573, HENRY, 12 week

old, male entire Standard Poodle Presenting complaint: Referred for dialysis treatment after acute kidney injury.


ECG (initially presented with sinus tachyarrhythmia- this resolved after single dose of lidocaine)

Serial Abdominal US- revealed bilaterally enlarged kidneys, with evidence of inflammation.

Serial blood biochemistry and complete blood counts- revealed severe azotemia, mild anemia, hypercalcemia

Abdominal radiographs- revealed bilaterally enlarged kidneys, evidence of hepatic inflammation.

Urine analysis, sedimentation and culture.

Leptospirosis titers- positive.

Urinary catheter placed, UOP monitored. Presented anuric initially, became polyuric post dialysis- this was closely monitored in order to try to closely match IVF inputs with the body’s outputs.

Treatments:

Single Dialysis treatment

Pantoprazole 0.7mg/kg IV q24

Ondansetron 0.2 mg/kg IV q 8

Doxycycline 5mg/kg PO q12 for 2 weeks (appropriate for later stage of Lepto)

Metronidazole 10 mg/kg IV q 12

Buprenorphine 0.01 mg/kg IV q 8-12 PRN

Cerenia 1mg/kg IV q 24

Free choice H2O

Feed and note interest q 8

Outcome:

Received single dialysis treatment. Was then hospitalized for 5 days before he was discharged and sent home.

Problem list:

AKI – polyuric – leptospirosis confirmed

Tachyarrhythmia – resolved

Hypercalcemia – resolved

Mild anemia – normal finding in a puppy vs. other causes

ICU Patient 859684, CREAMSICLE

12yo, castrated male, DSH Presentation: Presented in respiratory distress due to airway

obstruction. Was being managed for partial tracheal obstruction due to recurrent tracheal carcinoma vs. less likely granulation tissue associated with previous stenting. Has received previous courses of chemotherapy and radiotherapy. Abdominal mass discovered during most recent investigations.


Thoracic rads: tracheal soft tissue opacity; no evidence of pulmonary metastatic disease; bronchointerstitialpulmonary pattern unchanged from 4/2014

Abdominal rads: large cranioventral abdominal mass

Extended database: moderate respiratory acidosis (pH 7.246), moderate dehydration (PCV 43%, TS 8.5 g/dL, Na 157.2), mild hyperlactatemia (2.1 mmol/L); hypokalemia (3.63 mmol/L)

NIBP: 160 mmHg

CBC/CHEM: elevated AST 51 U/L; elevated Mg++ 3.2 mg/dL

TRACHEOSCOPY: previous tracheal stents intact; intra-thoracic intra-luminal tracheal mass largely occluding airway in previously stented portion

Abdominal US: Left cranioventral cavitated fluid-filled mass most likely arising from liver (vs. mesenteric) — ddxneoplasia vs cyst; free peritoneal fluid ddx hemorrhage, carcinomatosis, inflammation, infection; generalized hyper echoic liver; chronic renal changes, splenomegaly, jejunalcorrugation w/ mild jejunal & ileal thickening

POST-STENT EDB: resolution of respiratory acidosis (pH 7.347), normalized K+

CYTOLOGY (PENDING): tracheal wash, aspirates of abdominal mass, aspirates of intra-cavitary fluid from abdominal mass, peritoneal fluid

CULTURE (PENDING): tracheal wash

BIOPSY (PENDING): tracheal mass

Flex 4 (Creat, BUN, Mg, P): results pending

Crossmatch

Coagulation panel: wnl

Ascites cytology (In house): results pending

Treatments:

Placed on mechanical ventilator.

LRS @ 1.5ml/kg/hr +0.45% NaCl @1.5ml/kg/hr

Reglan 1mg/kg/day CRI

(1/4) Kmax 0.5meq/kg IV

Unasyn 22 mg/kg IV q8

Dex SP 0.1 mg/kg q24

Butorphanol 0.1-0.3 mg/kg/hr IV

Terbutaline 0.01 mg/kg IV q8

Midazolam 0.1-0.5 mg/kg/hr

Propofol 0.1-0.6 mg/kg/min

Cerenia 1mg/kg IV q24

Ondansetron 0.2 mg/kg IV q8

Glycopyrrolate 0.005mg/kg IV

Pantoprazole 1mg/kg IV q24

Norepinephrine 0.1meq/kg/min

Lasix 0.5mg/kg IV (one off dose given at 9am)

+/- RBC transfusion

Outcome:

Was maintained on the ventilator for 7 days in ICU, each time

weaning was attempted Creamsicle would respiratory obstruct.

The owner refused to consider humane euthanasia. Creamsicle

went into cardiac arrest on day 7 and after several rounds of CPR,

died.

Creamsicle

ES (Emergency Service) Patients 887116/114, HAZE and

MARLEY, 2 year old, spayed female DSHs

Presentation: Possible lily ingestion.

Investigations performed:

EXTENDED DATA BASE: A blood screen used to check kidney values, acid/base and electrolytes was performed. The initial results were within normal limits.

PROGRESS: Haze was admitted and started on intravenous fluids. She was offered food and water and her urination and vitals were monitored overnight. In the morning, urine was found in Haze's cage. She was transferred to fluid wards for continued treatment and monitoring by the internal medicine service.

TRANSFER TO INTERNAL MEDICINE; Haze was bright and alert for her physical exam. Her heart rate, respiratory rate, temperature, and blood pressure were within normal limits for a stressed cat. A possible heart murmur was heard on auscultation. However, it is difficult to be sure of this finding since she was breathing quite heavily at the time. Her abdomen was soft and nonpainful and no other abnormalities were noted on physical exam. Haze was maintained on IV fluids and blood and urine were collected.

BLOOD WORK: No abnormalities were noted on a standard chemistry screen. Her CBC was normal except for echinocytosis, which is most likely an artifact from sample handling. A limited chemistry screen was repeated daily to monitor BUN, creatinine, sodium, and potassium. Her chemistry values were within normal limits every day and she never showed more than a 0.1 increase in her creatinine.

URINALYSIS: No abnormalities were detected in her urine. A urine dipstick was repeated daily and never showed glucosuria or more than trace amounts of proteinuria which can be erroneous on the dipstick. Official urinalysis showed no protein or glucose and very well concentrated urine.

Treatments:

IVF (Plasmalyte) at 4ml/kg/hr for 48 hours

Monitoring BUN/CREAT/Electrolytes

Outcome:

Remained stable during hospitalization, no changes in BUN/CREAT/UA/electrolytes. Discharged and sent home.

ES patient 773870, ROXIE, 10yo,

spayed female, Boston Terrier Presentation: Painful at home. Pawing at face and eyes. Increased intraocular pressure OU.

Previously diagnosed with glaucoma- has been medically managed with carbonic anhydrase inhibitors, beta blocker (Timolol), and PG analogues OU for the last year.


Tonometry: IOP 56 OS, 58 OD

Fluorescein stain: revealed superficial corneal ulceration OD.

Schirmer Tear Test: 15mm OS, 18 OD

Transfer to Ophthalmology

Ocular US

Treatments:

IV mannitol

IV methadone

Continue with ocular medical management until surgery.

Outcome:

Bilateral enucleation scheduled.

ES patient 887883, CHARLIE, 2yo

castrated male Labrador Retriever Presentation: two day history of anorexia and discomfort. He vomited once two days ago, and

also passed a cloth object in his feces with some diarrhea. Today, he was taken to his primary veterinarian where serial x-rays of his abdomen were taken which were suspicious for a foreign body obstruction. Two weeks ago he had surgery for a gastrointestinal foreign body obstruction. He received an enterotomy and gastrotomy, where two pacifiers and some cloth material were removed


BLOODWORK: A mild inflammatory response was noted but the remainder of the values were within normal limits.

GASTROINTESINAL ULTRASOUND: Foreign material was observed in the early small intestines causing a partial obstruction with inflammation of the areas nearby and dilation of a portion of the small intestines.

Treatments:

SURGERY: An abdominal exploratory was performed in order to retrieve a foreign body from Charlie's small intestine. The foreign material (a pacifier) was found in the early small intestine. It was gently pushed backward into the stomach from where it was ultimately removed.

Outcome:

The procedure was completed without complication and Charlie's recovery from anesthesia was uneventful.

CHARLIE

ES patient 786789, MARIUS, 13yo

castrated male Bichon Frise Presentation: 3 day history of diarrhea. Blood noted in stool. Previously treated for IMTP 3 years ago.


Minimum database PCV/TS: 59/6.7

Complete blood count (CBC): This evaluates red blood cells, white blood cells and platelets. This test revealed a low platelet count (52.6K) and no other abnormalities. The platelet count was low at 52,600 (normal is 177,000 - 398,000)indicating a recurrence of his immune-mediated thrombocytopenia. Alternatively, it could represent consumption if platelets are being used by the body in another area, like the gastrointestinal tract.

Further diagnostics such as full bloodwork, an abdominal ultrasound and other tests are indicated to determine the cause of Marius' low platelet count. At this time, the owner elected to treat the diarrhea symptomatically and recheck a platelet count in 24 hours to see how the number is trending.

Treatments:

Metronidazole 10mg/kg PO BID 5 days.

Outcome:

Platelet count was rechecked 24 hours later, and dropped to 20,000. The owner rejected pursuing further diagnostics and elected to take Marius home monitor his quality of life and bring him to his regular vet for humane euthanasia when necessary.

ES patient 842084, CALLIE, 13yo

spayed female DSH Presentation: 12 hour history of being unable to stand up. She was last observed normal and able to

ambulate yesterday by her caretaker. Callie is a barn cat, who gets fed and cared for at least twice a day. Over the last few months she has been losing some weight and condition, despite a normal appetite.


NEUROLOGY CONSULT: On neurological examination some lumbosacral pain was noted. Mild right scapular muscle atrophy was noted. She had torticollis to the right. She had decreased placing/proprioception in her legs but had motor in all four. No menace response was detected bilaterally. Anatomic localization is suspected to be either brainstem vs. C1-C5 +LS pain. Possible causes of these signs include multifocal causes such as lymphoma vs vascular event vs other infectious/inflammatory causes.

BLOODWORK: Her complete blood count showed an elevated platelet count, her serum chemistry panel showed mildly elevated liver enzymes and her thyroid hormone level was markedly increased at 19.8.

Treatment:

We will start tapazole at 1/2 tablet twice a day along with the YD hyperthyroid diet.

Outcome:

It is difficult to determine if her neurologic signs are related to her hyperthyroidism. If she suffered a vascular accident then her signs should improve over the next few days. If her signs are more due to multifocal disease like lymphoma then she most likely will not improve or will get worse. Owner elected to take her home for the weekend, monitoring her neurologic status and starting the medication for hyperthyroidism to see if she is easy to get medications into. Her condition improved over the weekend and she was able to stand an walk on her own after several days.

ES patient 887476, CLAUDE, 1 yo

castrated male DSH Presentation: acute onset of vomiting which coincided with him ingesting bandage material.

Claude had a history of dietary indiscretion.


INITIAL BLOODWORK: An emergency blood panel was performed, the results of which were relatively unremarkable.

ABDOMINAL ULTRASOUND EXAMINATIONS: Claude's initial (12/5/14) abdominal ultrasound examination revealed gastric foreign material, with extension of the material through the pylorus and into the duodenum. His next ultrasound (12/6/14) examination showed that the foreign material had moved into the jejunum. Repeat ultrasound the following day (12/7/14) showed that the foreign material was still in the jejunum, with evidence of regional inflammation (peritonitis).

Treatments:

SURGERY: Claude was placed under general anesthesia, and an abdominal exploratory surgery was performed. Foreign material (cast padding) was identified in his jejunum and removed by enterotomy (incision into the intestines). No additional abdominal pathology was appreciated.

POST-OPERATIVE CARE: Claude recovered uneventfully from anesthesia and surgery. He was hospitalized on intravenous fluid therapy and analgesia.

Outcome:

Post operatively Claude was eating well on his own, and had no episodes of vomiting. He was discharged and sent home with oral analgesia.

ES patient 887941, CARLOS, 2yo

castrated male DSH Presentation: 24 hour history of straining to urinate. He had been urinating small, dime size

amounts in the litter box throughout the day. Recently his litter brand and type was changed from a natural walnut based brand combined with a lightweight clay litter, to another brand.


URINE ANALYSIS: A urine sample was obtained via cystocentesis. An in house urinalysis revealed that glucose, ketones, and bilirubin were all negative. His urine was well concentrated at >1.050. Protein was found to be 300 mg/dL. Urine sediment revealed no significant abnormalities. There were multiple fat droplets but very few cells. No bacteria were seen.

URINE CULTURE: A culture was submitted to rule out infection. Results are pending. We will call you when they become available.

On PE bladder was large but soft and expressable.

Treatments:

SUBCUTANEOUS FLUIDS: 150mL of isotonic crystalloid fluids were administered under Carlos’s skin. He may have a fluid pocket over the area for the next 24 hours.

Buprenorphine 0.03mg/kg PO q8

Prazosin 0.5mg PO BID

Recommended management changes: water fountains, adding more litter boxes, switching back to regular litter, increasing wet food/moisture in diet, monitoring urination, decreasing stress levels.

Outcome:

Discharged and sent home on medical management, and monitoring.

ES patient 887952, DAKOTA, 5yo

spayed female Rottweiler Presentation: referred for for further evaluation of lytic toe mass (diagnosed at regular

veterinarian).


LYMPH NODE ASPIRATE: An aspirate of the lymph node draining her toe was obtained and submitted for evaluation by the pathologist to look for evidence of metastatic disease (spread of cancer). The results are pending, you will be notified of the results.

SURGERY CONSULTATION: The surgeons felt that Dakota was a good candidate for toe amputation.

BLOOD WORK: Blood work was submitted to determine if Dakota is a good anesthetic candidate.

Referring vet Radiographs of all 4 limbs (from paws to elbow and knee). Revealing a lytic lesion on 4th digit of her right front paw. Also bilateral hip dysplasia.

Thoracic radiographs (3 view): wnl, no signs of metastatic disease.

Treatment:

Digit amputation, with biopsy of mass.

There are several possibilities for the swelling of Dakota's toe. The most likely cause is a tumor with less likely causes being an infectious process or benign growth. Common malignant tumors of the digits include squamous cell carcinoma, malignant melanoma, and other various sarcomas including osteosarcoma. The most likely cause in Dakota was though to be squamous cell carcinoma given her breed and coloring as well as the bone lysis.

Outcome:

Transferred to the surgery department for digit amputation and further diagnostics. Will continue on to oncology pending biopsy results.

DAKOTA

ES patient 825516, ABIGAIL, 11yo

spayed female English Bulldog Presentation: 3 day history of diarrhea. She also vomited up her bland meal last night. She was seen and treated by her

primary veterinarian about 2 weeks ago for diarrhea. Over the last 6 months Abigail has been losing weight (estimated 10 lb), having intermittent diarrhea every 3-4 weeks that is generally self-limiting and occasional vomiting. She has also had increased respiratory noise progressively over time. Abby is exercise intolerant which has been ongoing due to her arthritis and historic cruciate tears bilaterally.


Emergency blood work: NOVA: This is an emergency blood screen that was used to assess Abigail's electrolytes, glucose and renal values. Findings were supportive of a mild dehydration.

Abby was transferred to the Internal Medicine Service on 12/7/2014:

Complete blood count (CBC): normal red cell, white cell and platelet counts

Chemistry panel: decreased albumin and low globulins *low blood proteins), mildly elevated ALP.

Normal kidney values and electrolytes and blood glucose.

Thoracic radiographs: no evidence of metastasis or abnormalities

Abdominal ultrasound: GIT thickening diffusely. Recommend intestinal biopsies.

Urinalysis: A urine sample was obtained by ultrasound-guided cystocentesis. NAD.

Urine culture: Results are pending. We will contact you when results are available.

Fecal float: this is a test for intestinal parasites, NAD.

Fecal screen: this is a test for campylobacter and salmonella, NAD.

GI panel: B12 and TLI pending

Treatments:

Metronidazole

IVF

Cerenia

Panacur dewormer

Food trial.

Outcome: Discharged, sent home on medical management. Recommended intestinal biopsies- owner will consider. Also recommend airway exam if owner decides to pursue biopsies.

ES patient 887956, SPARTACUS, 3yo

castrated male Pit bull mix Presentation: Referred after being recently treated at his primary vet for suspected kidney injury and dehydration.

Investigations performed.

***EMERGENCY SERVICE DIAGNOSTICS, TREATMENTS, AND PROGRESS***

BLOOD PRESSURE: Spartacus's blood pressure was increased at 210 mmHg. This was likely due to pain and kidney disease. His blood pressure normalized later in his hospitalization.

EMERGENCY BLOOD PANEL: Spartacus had elevated kidney values and some electrolyte abnormalities. His kidney values were improved from last check prior to referral. [Elevated kidney values (BUN 50, Creatinine 2.3) elevated sodium (162), decreased potassium (3.7), and mildly elevated chloride (124).]

ELECTROCARDIOGRAM: An eletrical tracing of his heart was performed due to the low heart rate.

Spartacus had sinus bradycardia (atropine responsive), with a heart rate of 64 beats per minute. This was likely secondary to his illness and improved as he improved.

ABDOMINAL ULTRASOUND: Abdominal ultrasound revealed severely inflamed and enlarged kidneys consistent with acute kidney injury

***MEDICINE DIAGNOSTICS, TREATMENTS, AND PROGRESS***

COMPLETE BLOOD COUNT (12/7): He has white blood cell changes consistent with infection or inflammation. [Elevated white blood cell count (23,000) with a left shift (19,000 segmented neutrophils), increased monocytes (2,300) and reactive lymphocytes.]

BLOOD CHEMISTRY (12/7): Spartacus's kidney values remained elevated, and his electrolyrtes improved somewhat overnight. Spartacus also had an elevation in one of his liver enzymes, ALP, which can occur with leptospirosis. [Elevated renal values (BUN 39, Creatinine 2.7), increased sodium an chloride (159 and 122 respectively), decreased potassium (3.7), and increased alkaline phosphatase (517).]

URINALYSIS: He was not concentrating his urine with a USG of 1.007 (hyposthenuric) and had some blood present in his urine (4+). URINE CULTURE: Negative

SERUM LEPTOSPIROSIS TITER: Spartacus was tested for an immune response to leptospirosis. He had a very elevated titer, consistent with recent infection

SERIAL MONITORING OF KIDNEY VALUES: Over the few days in the hospital, Spartacus's kidney values initially returned to the normal range. They increased slightly as fluids were weaned. At the time of discharge, completely off fluids, his valuse were slightly above the normal range (indicating at least 75% loss of kidney function) with increased phorphorusand potassium (electrolytes excreted by the kidney). Spartacus's kidneys may recover further over the next few weeks, or he may have residual chronic kidney injury that will require management.

Treatments:

During initial hospitalization in ES:

IVF

Methadone IV

Ampicillin

Enrofloxacin

Transferred to Medicine department for further hospitalization, diagnostics and treatment.

Outcome:

Was hospitalized for several days on supportive care before Leptospirosis titers came back positive. He was started on Doxycycline treatment and continued on IVF, pain management, and gastric protectants. He became much brighter, began eating well, and was sent home on oral treatment.

ES patient 887954, ZAR, 8yo intact

male German Shepherd Presentation: acutely unable to bear weight on right hind leg. Zar lives outside and is a guard

dog in a junk yard. He likes to jump on an off of cars, and this is likely how he injured himself.


SEDATED PELVIC RADIOGRAPHS: Zar was sedated for radiographs of his pelvis. These radiographs showed a right craniodorsal coxofemoral (hip) luxation. (Official report pending)

NSAID PANEL: This bloodwork was performed to assess Zar's liver and kidney values. There was a mild increase in AST likely secondary to muscle damage sustained during his trauma.

URINALYSIS: During his anesthesia, Zar was dripping red-tinged urine from his prepuce. He was catheterized and a urine sample was obtained. There was a small amount of protein and occasional red blood cells on sediment exam.

Treatments:

CLOSED HIP REDUCTION AND EHMER SLING PLACEMENT: Zar was placed under light anesthesia. Using manual force the head of the femur was replaced into the acetabulum. A sling was placed to keep Zar's right leg in a non-weight bearing position with the head of the femur in the acetabulum of the pelvis. Radiographs were taken post-reduction and post-sling placement to confirm that there was no re-luxation.

Outcome:

Zar was sent home to recover indoors with strict rest. He was placed on tramadol, rimadyl, and acepromazine (as needed, if becomes anxious indoors). Recheck appointment in 1 week for repeat hip radiographs to check sling placement and healing.

ES patient 887967, BIGZ, 2 yo,

castrated male Boxer Presentation: 2-3 day history of coughing. Three days previous he had and episode

of vomiting, which had since resolved. Shortly after the cough resolved Bigzdeveloped a cough. The cough is exasperated by exercise.


THORACIC AND NECK RADIOGRAPHS: Normal cardiac structures. No evidence of pneumonia was observed on the radiographs.

Treatment:

Bigz's radiographs showed no evidence of pneumonia. Given the sensitivity on tracheal palpation and his history, we are treating him for tracheitis (inflammation of the trachea). Possible causes include infections such as kennel cough, allergies or traumatic irritation such as from a pulling on a leash excessively. We are treating him with an antibiotic for a potential infection, such as Bordetella.

Doxycycline 150mg PO BID 10 days.

Outcome:

Sent home on medication for tracheitis. Recovered well per owner on follow up call. No further complications.

ES patient 768537, GENEVIEVE, 13yo

spayed female Yorkshire Terrier Presentation: yelped and started limping on her right front paw today during

her walk. She was initially non-weight bearing on her right front limb, but she seems to have improved since the incident. Genevieve has a history of shifting intermittent lameness, a cause for which has never been identified. Genevieve has been previously seen here at the hospital for a protein losing nephropathy, for which she is being medically treated.


There were no abnormalities on orthopedic examination

Lameness may be caused by a variety disease processes such as inflammation, infection, neoplasia or trauma involving bones, muscles, nerves, joints, tendons, or ligaments. Radiographs of the affected limb may help determine a cause of the observed lameness. In some cases, advanced imaging (MRI/CT) may be necessary to appropriately determine a cause of lameness.

Diagnostic investigations rejected by owner.

Treatments:

Tramadol 12.5mg PO BID

Outcome:

Sent home on pain management. Limping resolved on medication per owner when I called for update.

Rotation ReflectionMy rotation at the University of Pennsylvania consisted of 2 weeks in the ICU and 2 weeks in the Emergency Service. In the ICU the students are expected to write daily SOAPs on all of the patients, participate in daily rounds, assist the nurses with treatments, and write patient discharge letters. The day starts at 6:50am, as ‘pick ups’ or transferred patients from other departments are moved into ICU at 7am and students are expected to assist with this and any diagnostic procedures necessary. We would usually finish by 7pm. During my time in ICU we were quite busy, but still managed to get daily rounds with the senior clinicians. Some of the round topics included: blood gas analysis, ventilator basics, fluid therapy, septic peritonitis/SARS/ARDS/DIC/Sepsis, brachycephalic airway syndrome, CPR, ECG interpretation, acute kidney injuries. We also got to participate in a cadaver lab where we were able to practice cut downs, thoracostomy tube placement, tracheostomies, pericardiocentesis, thoracocentesis. I found the rounds and cadaver lab to be invaluable. During my time in ICU we had several ventilated patients, with very complex cases. I had not experienced this level of complexity of care before and it was a really amazing learning experience.

During the Emergency Service rotation students get to experience a high volume case load. You are expected to do a full physical exam on your patients, obtain a full history from the client, and then formulate your own differential list, diagnostic and treatment plans and present them to the attending clinician. Their expectations are high, so it can be a little nerve wracking at first, but it really pushes you to think things through and be able to explain why you are making all your decisions. You are pushed to make decisions and justify them- the way you will need to in a few months when you qualify. You also receive rounds twice a week during the ES rotations. The ES rounds topics included- emergency triage, ophthalmic emergencies, foreign body obstruction case evaluation, and day 1 fears (we talked about cases we are scared/nervous to see next year when we get out into practice on our own).

Overall, the ICU/ES rotation at Upenn was an amazing experience and I would highly recommend it.

U penn case log lauren ritchey

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