So what are we going to ask Mrs Humphreys?
Now we've got a good history we move onto a clinical exam. Here's what we find:
So we're thinking along the lines of an endocrine disease. Which in particular?
Hyperadrenocorticism is our top DDx. You chat to Mrs H and she's happy to investigate further, so what diagnostics should we do initially?
Here are the results of our initial tests:
Great answers. We've eliminated diabetes mellitus. The increased ALP and ALT (with ALP increased by a higher proportion), high cholesterol, stress leukogram and isosthenuria all support a diagnosis of hyperadrenocorticism.
Shall we do an ACTH stimulation test or a low-dose dexamethasone suppression test (LDDST) next?
We've got some differences of opinion! It's OK, Rosanne provides some reassurance that it's not a clear-cut answer!
What are the pros and cons of each test?
Tim makes an important point worth considering:
With Simon we've got the luxury of having results for both tests!
From these results in conjunction with the clinical signs and biochemistry, we're sure Simon has got hyperadrenocorticism.
The fact that his cortisol was suppressed at 4hrs but not at 8hrs in the LDDST makes the pituitary-dependent form more likely.
There are a couple of other pointers too – the pituitary-dependent form is more common (85% of cases), particularly in small dogs.
How could we tell definitively whether it's pituitary- or adrenal-dependent?
Plasma ACTH will be high in dogs with PD-HAC and low in dogs with AD-HAC.
Do we think these further tests are necessary in Simon?
We're happy that Simon has the pituitary-dependent form; no other tests are performed.
What should we recommend in terms of treatment?
Yes, it's important to follow the cascade!
What are we going to recommend in terms of monitoring?
What sort of prognosis should we give Mrs H? How long do we think it will take for things to improve?
Simon was started on trilostane and did really well…
Excellent outcome! Thank you very much to Rosanne for such a brilliant first session, hope everyone found it useful!