For our first #VetFinals case of 2017 we were joined by Dr Rosanne Jepson BVSc (Dist) MVetMed PhD DipACVIM DipECVIM MRCVS, a Lecturer in Small Animal Internal Medicine at the RVC.
So, what's the first step in approaching this case?
The general consensus was to begin by taking a history. Great responses included questions about stranguria, whether she was fully voiding/dribbling urine, whether she was PU/PD, and general health questions including access to toxins:
Questions specifically about urination were summarised by Rosanne:
We received further details about the history of the patient.
The conversation moved on to discuss differentiation of incontinence:
It's also worth considering whether the owner is leaving the dog for extended periods of time – is this causing her to urinate inappropriately?
However, it appears that Bella knows that she's urinating… but what about the blood-stained urine?
A great response was listed with many differentials considered:
And don't forget to consider the differentiation of frank blood versus haemaglobin!
Now it's time for a physical examination of Bella. Here's what we found:
We localised the problem at this point.
Don't forget to consider the entire LUT, not just the bladder! And remember that pollakiuria and stranguria are not seen with renal disease – PU/PD occurs in these cases.
Time to move on to the next step of the case – how are we going to investigate this problem?
And don't forget the value of the various Dipstick tests!
And another important point about urine sediment exam:
Rosanne made a really great point here about further physical examination techniques that could be invaluable in this case:
At this point a cystocentesis was performed and we submitted the urine for analysis. Rosanne gave us the results next:
Broad spectrum antibiotics were considered by many students at this point. However we don't have our culture results back and do not know that an infection is present here. Instead, anti-inflammatories would be more appropriate.
And don't forget the value of further imaging in these cases:
We get the results of our urine culture back.
And move on to radiography:
Radiographic quality was first considered.
And the abnormalities were correctly identified:
Don't forget that a urolith doesn't always mean crystalluria!
We began to consider the types of uroliths that may be present to give this radiographic appearance.
But it's important to remember the test results we've already accumulated:
The spiculated appearance is more common with CaOx stones
So, what next?
And don't forget the minimally invasive methods of removal!
Rosanne summarised the options for us:
And in reality, here's what happened:
What should you always remember to do post-surgery?
The analysis came back on Bella's stones:
To finish, Rosanne summarised the post-operative considerations for us:
We should aim for a USG of less than 1.025, so allow the patient to have plenty of water. In this situation, the diet was not changed.
Please see the ACVIM Small Animal Consensus Recommendations on the treatment and prevention of uroliths in dogs and cats http://onlinelibrary.wiley.com/doi/10.1111/jvim.14559/full …
A massive thanks to Rosanne for a great session to kick off the 2017 series! Join us on Thursday 23rd March at 8pm for a session with Kate White on sedation/anaesthesia of the difficult/aggressive dog!