Lets start with the history…
Let's start with thinking about Jack, a 10yo FN cross breed with a four week history of PUPD. Qs for owner? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
https://twitter.com/VetFinals/status/580459875345567745
@VetFinals How much is she drinking? How much is she urinating? Is the urination conscious? Any other changes/ problems? #VetFinals
— Andrew Beer (@andybeer11) March 24, 2015
https://twitter.com/SonnyBacigalupo/status/580460066387726336
@VetFinals any changes in appetite or weight? How much is he drinking and weeing #isheactuallyPUPD? #vetfinals
— Annie Mears (@Annabellemears) March 24, 2015
@VetFinals Is there anything else abnormal about her apart from the PUPD? #VetFinals
— Dr Minnie the Veterinarian (@minniethevet) March 24, 2015
.@minnieliddell Good question. How would you define PD? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
https://twitter.com/Lauren_Porteus/status/580461027273347072
Yes all great ideas. Measure each time water bowl filled up. Don't forget to measure how much add to food #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
Would you measure over just one 24 hr period? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
@VetFinals No, take an average over a few days if possible #vetfinals
— Emily Windham (@emilykwindham) March 24, 2015
The owner had not quantified water intake but said she was emptying his water bowl several times a day #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
Any other important Q's for the history of this dog with PD? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
@VetFinals when change noted? Diet change? Change in exercise? Environment? Stressors? Concurrent dz? #vetfinals
— Sinéad Kenna (@SinbadKenna) March 24, 2015
@VetFinals is the dog on any other meds? Large or small volumes? Little and often? #Vetfinals
— Isabelle Lawn (@IzzieLawn) March 24, 2015
Great suggestions for other Q's in Hx. Appetite was possibly increased. No diarrhoea/vomiting had been observed. Otherwise well #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
And onto the clinical examination…
What would you looking for on your clin exam of this dog with PDPU? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
heart and resp rate, mucous membranes, CRT, peripheral pulses #vetfinals
— Jessica Quinlan (@JessQ12345) March 24, 2015
@VetFinals abdominal discomfort, urine staining, bladder tone/fullness, feel of kidneys, hydration status #vetfinals
— Sinéad Kenna (@SinbadKenna) March 24, 2015
@VetFinals #vetfinals
skin changes, dischage fom the vulva, palpate LNs and thyroid, enlarged liver or kidneys or lumps in the abdomen— JAMES (@4565BRADY) March 24, 2015
@VetFinals has it put on any weight? Potbellied appearance? Any skin or coat changes to indicate endocrine? #VetFinals
— Annie Mears (@Annabellemears) March 24, 2015
You should already be thinking about differential diagnoses! Will help with Hx and clin exam q's #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
All sensible suggestions. Findings in Jack (Jackie?): BCS 5/9. Abdominal palpation- enlarged organ in cranial abdomen? Thoughts #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
@VetFinals hepatomegaly? #VetFinals
— Andrew Beer (@andybeer11) March 24, 2015
.@4565BRADY Yep could be liver. Seemed to be in cranio-ventral abdomen. Make sure not stomach #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
Thoughts on differential diagnoses?
So, Hx doesn't tell you much apart from PDPU. Clin exam not much either. What are your differential diagnoses for PDPU? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
https://twitter.com/SonnyBacigalupo/status/580466034001469441
@VetFinals endocrine: DM, HAC, hypothyroidism, hyperT4(cat), hypoadenocorticism; psychogenic PD; #vetfinals
— ana oliveira (@anaoliveira00) March 24, 2015
https://twitter.com/andy_yale1/status/580466156747800576
@VetFinals infection/neoplasia (esp. lymphoma and anal sac adenocarcinoma)/endocrine (diabetes mellitus, HAC) #vetfinals
— Dr Minnie the Veterinarian (@minniethevet) March 24, 2015
@Vetfinals endocrinopathies, hypercalceamia, hypo K, UTI, glomerulopathy, liver dx, polycytheamia, iatrogenic CCS/diuretics #vetfinals
— Ben Harvey (@BHarvey189) March 24, 2015
diabetes mellitus, cushing's, splenomegaly, hypercalcaemia of malignancy, chronic kidney disease, pancreatitis.. #vetfinals
— Jessica Quinlan (@JessQ12345) March 24, 2015
.@SonnyBacigalupo Liver Dx great suggestion. Why do you see PDPU in liver Dx then?? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
@VetFinals @SonnyBacigalupo due to decrease urea and therefore cannot get concentration gradient in kidney #vetfinals
— Ben Harvey (@BHarvey189) March 24, 2015
.@KatieOffer1 @SonnyBacigalupo Yep, it is to do with reduced urea production by liver. Why does low urea cause PDPU then? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
@VetFinals decreased urea synthesis leading to medullary washout and inability to concentrate urine? #vetfinals
— Dr Minnie the Veterinarian (@minniethevet) March 24, 2015
My DDx. Renal Dx, Liver Dx, endocrine (DM, HAC, addisons), hypercalcaemia, toxaemia/sepsis #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
And don't forget psychogenic polydipsia-highly strung dogs #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
Liver Dx must be up there. And DM, def tumour causing hyerCa. So what tests would you do? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
So what tests should we perform?
@VetFinals full haematology, biochemistry and urinalysis is a good starter #VetFinals
— Andrew Beer (@andybeer11) March 24, 2015
https://twitter.com/JessQ12345/status/580470088316424193
So most people have suggested urine first, which is a great idea in any animals with PDPU. REsults to follow #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
Urinalysis
SG: 1.010
pH 7.5
Protein: +
Glucose –ve
Ketones –ve
Blood/haemoglobin –veAny Dx this dog definitely doesn't have? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
https://twitter.com/andy_yale1/status/580470260891033600
Urine SG really important too. Hypersthenuric urine (SG >1.030) makes PU/PD very unlikely. #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
Biochem next as everyone suggested #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
Serum biochemistry demonstrated ALP (631IU/L [ref <140]), ALT (195IU/L [ref <59]) and AST (43 [ref <32]). Thoughts? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
Here's the full biochemistry- sorry for the fuzziness #vetfinals pic.twitter.com/QSARZQsRTy
— Vet Finals (@VetFinals) March 24, 2015
@VetFinals increased liver parameters, ALP and ALT quite high- liver damage, AST less high (and less specific) #vetfinals
— Sinéad Kenna (@SinbadKenna) March 24, 2015
https://twitter.com/Lauren_Porteus/status/580471206043918337
@VetFinals @anaoliveira00 Do a BAST!! #VetFinals
— Andrew Beer (@andybeer11) March 24, 2015
Can see massively elevated enzymes with completely normal function We did a BA stim test as Liver Dx a def possibility #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
Bile acid stimulation test. Pre prandial 7 umol/l(reference <10.0). Post prandial 26 umol/l (reference <15). what do you think? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
@VetFinals impaired liver function in combination with hepatocellular damage – not good #vetfinals
— Annie Mears (@Annabellemears) March 24, 2015
@VetFinals Compromised liver function, not great as function not usually affected until large part of liver damaged #vetfinals
— Sinéad Kenna (@SinbadKenna) March 24, 2015
We did CBC too, but no abnormalities to note. Imp to check WBC count (infection?), for signs of anaemia (chronic Dx?) #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
.@minnieliddell Unfortunately mild to moderate increase in BAs can just suggest bile stasis. #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
HAC relatively common. signalment Ok for that Dx. Elevated liver enzymes fit. Big liver. How are you going to test for it? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
@VetFinals ACTH stim test #vetfinals
— Dr Minnie the Veterinarian (@minniethevet) March 24, 2015
@VetFinals LDDST? #vetfinals
— Sinéad Kenna (@SinbadKenna) March 24, 2015
@VetFinals ACTH stim and resting cortisol? #VetFinals
— Andrew Beer (@andybeer11) March 24, 2015
So yes, ACTH or LDDS test. Pros and cons of each. How many cases of HAC will you pick up by doing an ACTH stim test? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
@VetFinals @VetFinals ACTH stim – lower sensitivity so false negatives! But good specificity? #vetfinals
— Isabelle Lawn (@IzzieLawn) March 24, 2015
Thanks for answers. ACTH stim test. Only moderately high sensitivity. IDs Approx 85% of PDH and 60% of ADH. #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
ACTH has advantage of the best specificity of screening tests so few false positives #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
What about LDDs test? More or less sensitive than ACTH? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
@VetFinals ACTH is less sensitive #vetfinals
— Robert Peckham (@PeckhamRobert) March 24, 2015
@VetFinals and LDDST can't detect iatrogenic HAC #vetfinals
— Robert Peckham (@PeckhamRobert) March 24, 2015
.@PeckhamRobert you all know your endo! LDDS More sensitive test – should detect nearly 100% of ADH and up to 90-95% of PDH cases #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
BUT LDDS lower specificity (40-50%) therefore more false positives. so think about relative sense and spec of each test #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
We did an ACTH stim test: Cortisol pre ACTH: 155nmol/l (ref 50-250). Post ACTH: 931nmol/l. thoughts?? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
@VetFinals post stim >600nmol/l so diagnostic of HAC (if clinical signs present)? #vetfinals
— Isabelle Lawn (@IzzieLawn) March 24, 2015
.@IzzieLawn Whole clinical picture needs to fit. I agree. Remember we have tried to rule out other causes of PDPU too. #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
https://twitter.com/andy_yale1/status/580476689660141568
.@andy_yale1 Yes important to differentiate PDH from ADH. Which is more common?? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
@VetFinals @andy_yale1 PDH? #VetFinals
— Andrew Beer (@andybeer11) March 24, 2015
So PDH far more common than ADH. 80% of dogs have PDH #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
.@andybeer11 @BHarvey189 Imaging would be really useful in this dog, both to look at the liver and also the adrenal gland size #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
So this is the liver: Large, and more echogenic. Likely steroid hepatopathy #vetfinals pic.twitter.com/7EV210Ifq6
— Vet Finals (@VetFinals) March 24, 2015
.@andy_yale1 So, yep, one atrophied in ADH and one enlarged. both enlarged (or normal size) in PDH. Check your notes as to why #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
As if by magic here is one adrenal gland. >7.5mm width is suggestive of hypertrophy. Other one was similar #vetfinals pic.twitter.com/zasTE238nl
— Vet Finals (@VetFinals) March 24, 2015
So it looks like this dog has….? #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
https://twitter.com/andy_yale1/status/580478673045839872
So an outcome of pituitary dependant HAC was diagnosed. And a few tweets to summarise…
So to summarise, although dog didn't have classic signs of HAC, not all animals do. Revise the classical signs if you are unsure #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
Make sure the animals is truly PDPU first. Remeber to distinguish from incontinence. Quantify water intake if possible #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
Start thinking about DDX. Good Hx and clin exam to help rule in/out some of your DDX #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
Start thinking about DDX. Good Hx and clin exam to help rule in/out some of your DDX #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
Urinalysis first pin any animal with PDPU. If SG>1.030ish, you are barking up the wrong tree and animal unlikely PDPU #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
Biochem +-CBC to help rule in/out more DDX. Don't forget to check liver function by way of bile acids. And measure calcium too #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
Hopefully don't have many DDx left now. HAC, DI, psycogenic polydipsia often remain so imaging usually next. #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
This dog had a big liver that looked like steroid hepatopathy, and enlarged adrenals too #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
Suspicious of HAC so now CONFIRMATION tests either ACTH or LDDS. Remember pros and cons and sense spec. #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
Sometimes an easy diagnosis, sometimes really tricky. And Tx, well Trilostane (vetoyl) is licencesed, but monitor closely #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
That's all folks! Have a great evening! Over and out #vetfinals
— Vet Finals (@VetFinals) March 24, 2015
#vetfinals 