EVP Module 1 – October 2014
Case 1:
CASE DISCLOSURE #1
You are a cattle vet who specializes in infectious disease and has access to all of the latest tools
and techniques at your fingertips. You are the opposite of technology constrained.... if there is a
new technology, you have it, if there is a new medical or surgical approach, you can do it, and
people know it. As a result, you receive the best clinical cases and you see, and consult on, the
most genetically valuable animals in the country.
One day, in August an interesting case shows up at your door. An 8 MO Holstein bull that is in
the top 0.05% for milk, fat and protein in EPD scores, shows up at your clinic without any
warning. You provide clinical service for this client all the time, and he is very particular. This
is the first time that he has shown up unannounced at the clinic with an animal and, on this
occasion, he is in a panic. This bull has never been off the farm. He is penned by himself, but in
the main ‘genetics barn’ with their string of show heifers and other valuable developing bulls.
The owner reports that the calf was fine last night, but had stopped eating this morning and now
appears depressed. You ask the client to unload the bull while you put on coveralls and then
head to the back to look at him.
You perform a quick physical exam on the bull, and observe the following:
HR
RR
R Temp
Joints
MM
Abdominal contour
Ruminations
Attitude
90
50
105.6
Slight abdominal effort
Normal
Mild nasal discharge
Slight distension in R cranioventral region
0
Depressed
Your Problem List includes:
Based on your problem list, try to identify which organ systems are involved with each
problem. Please list the organ system that is involved with each problem on your case summary
worksheet
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EVP Module 1 – October 2014
Case 1:
CASE DISCLOSURE #2
Applying Occum’s Razor, try and determine:
a. Whether the observed problem in each organ system is likely physical or functional
b. Which organ dysfunction can be classified as primary, and so causative of the secondary
dysfunction in the other organ systems.
On your case summary worksheet please list each of your organ system dysfunctions as
either primary or secondary.
If all has gone well, you have now interpreted the case information in a way that can help inform
the key parts of your quizzical quadrangle (QQ).
Be ready to explain how these key pieces of information provide guidance to your clinical
decision-making?
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EVP Module 1 – October 2014
Case 1:
CASE DISCLOSURE #3
You have determined that you want to further investigate the respiratory system. You auscult the
thorax and hear a mild increase of a high-pitched sound on inspiration, near to the right elbow.
As you are listening to the chest you notice some intercostal breathing.
1. Which of the following is the best statement regarding the clinical signs in this case:
a. The elevated respiratory rate can be explained by a transport-associated increase in parab.
c.
d.
e.
sympathetic tone
The respiratory rate is likely to decrease with intravenous, 1.3% bicarbonate infusion
The heart rate is likely to decrease with intravenous fluid administration.
The respiratory rate is likely to decrease with intranasal oxygen therapy
The RR is expected, given the circumstances.
2. Which of the following is the best statement regarding the respiratory signs in this case:
a. Increased effort on inspiration indicates intra-thoracic disease
b. Increased sounds on auscultation indicate lung tissue pathology
c. Intercostal breathing suggests intra-thoracic disease
d. Intercostal breathing and increased expiratory effort are due to a stress response from
transport
Write a simple case definition at this point based on what you know:
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EVP Module 1 – October 2014
Case 1:
CASE DISCLOSURE #4
With an initial Case Definition of Severe, Acute, Intra- and Extra-Thoracic Respiratory
Disease, and the information about the case prognosis, you decide to press on with case
management.
You know the calf has an elevated rectal temperature and evidence of thoracic pain, based on his
intercostal breathing.
3. What pathologic processes do you suspect with these clinical signs?
4. Which of the following immunological receptor mechanisms are likely to have been
stimulated in this calf?
a. PAMPS on macrophages and MHC molecules on T cells
b. DAMPS on neutrophils and MHC molecules on B cells
c. TLRs on macrophages and MHC molecules on T cells
d. PAMPS from a microbe and TLRs on macrophages
e. DAMPS from a microbe and TLRs on macrophages
5. Which of the following immunological effectors are likely to be active in this calf?
a. Soluble innate immune components (complement, type 1 interferons, antimicrobial
b.
c.
d.
e.
peptides, C reactive protein, immunoglobulins)
Cellular innate immune components (macrophages, neutrophils, basophils,
eosinophils)
Soluble innate, and adaptive, immune components
Cellular innate, and adaptive, immune components
Other (please specify)
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EVP Module 1 – October 2014
Case 1:
CASE DISCLOSURE #5
6. Which of the following lymphoid organs are activated in this disease process?
a. The primary lymphoid organs (thymus, spleen and the pre-scapular lymph nodes)
b. The primary lymphoid organs (bone marrow, thymus and spleen)
c. The secondary lymphoid organs (bone marrow, spleen and the pre-scapular lymph
nodes)
d. Both primary and secondary lymphoid organs (pre-scapular lymph nodes, bone
marrow, and spleen)
e. Both primary and secondary lymphoid organs (pre-scapular lymph nodes, mucosal
immune system, and spleen)
7. Which of the following antigen processing pathways are likely to be active in this calf?
a. MHC Class I on macrophages, with presentation to TCR and CD8 co-receptors
b. MHC Class II on neutrophils, with presentation to CD8 co-receptors
c. MHC Class II on macrophages, with presentation to TCR and CD4 co-receptors
d. MHC Class II on B lymphocytes, with presentation to TCR and CD4 co-receptors
e. Other (please specify)
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EVP Module 1 – October 2014
Case 1:
CASE DISCLOSURE #6
You can now explain the elevated rectal temperature in the calf.
8. How does the rectal temperature influence your clinical reasoning in the quizzical
quadrangle (QQ)?
You decide that you need to treat this calf. But before you make the next move you decide some
additional diagnostics are needed.
9. Which, of the following, is the best approach to take?
1. Collect a CBC and a deep nasal pharyngeal swab to improve the reliability of your
diagnosis
2. Collect a CBC and respiratory ultrasound to inform antibiotic choice.
3. Collect a deep nasal pharyngeal swab to identify the pathogens involved.
4. Collect a CBC and serum lactate to refine prognosis and therapy.
5. Perform a thoracic ultrasound to refine prognosis, therapy and herd management.
10. How does your diagnostic approach in question 9 influence your clinical reasoning in
the quizzical quadrangle (QQ)?
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EVP Module 1 – October 2014
Case 1:
CASE DISCLOSURE #7
One hour after arrival you are organizing and assimilating the data from your CBC, CHEM Panel, deep
nasal swab and thoracic ultrasound
You receive the following results.
(Editors Note: “… . but we’re Food Animal Veterinarians? Isn’t that impossible … to acquire the
results of those assays so rapidly, and at an affordable price?”)
PCV
Total Protein
Albumin
Globulin
Na+
ClK+
CO2
BUN
Creatinine
Lactate
Glucose
WBC
Neutrophils
Neutrophils %
Bands
Bands %
Lymphocytes
Lymphocytes %
Monocytes
Monocytes %
RBC
HGB
HCT
MCV
MCHC
Fibrinogen
Case
Normal
28
8.6
3.6
5.0
140
89
5.9
19
45
3.1
3.5
85
32-36 %
6.5-7.5 g/dl
3.2-4.0 g/dl
2.5-5.0 g/dl
132-140 mEq/L
98-106 mEq /L
3.6–5.6 mEq /L
20-31 mEq /L
20-30 mg/dl
1-2 mg/dl
< 1.5 mmol/L
45-75 mg/dl
Case
Normal
22.0
8.8
40
1.1
5
9.1
45
0.6
3
5.0
9
24
30
25
4-12 x 109/L
0.6-4.0 x 109/L
15-45%
400
< 400 mg/dl
0-2%
2.5-7.5 x 109/L
0-1.5 x 109/L
n/a
5-10 x 1012/L
8-15 g/dl
24-46%
40-60 fl
30-36 g/dl
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EVP Module 1 – October 2014
Case 1:
Thoracic Ultrasound:
Comet tails refractions from visceral pleural surface
Echogenic fluid in pleural space
Small echogenic and hypoechoic luscencies in parenchyma
Based on this information you update your problem list, suspected organ system involvement
and your QQ.
11. You can now update your case definition to which of the following?
a.
b.
c.
d.
e.
Severe, acute, bacteremia, pleuritis and bronchopneumonia.
Severe, acute sepsis
Severe, acute, pleuritis and bronchopneumonia with systemic shock.
Severe, acute, pleuritis and bronchopneumonia
Severe, acute, pleuritis and bronchopneumonia with systemic shock and chronic
inflammation.
12. You then initiate a treatment. The most prudent course is:
a.
b.
c.
d.
Ceftiofur sodium SQ and Fluxinin IV.
10L Lactated Ringers IV, Fluxinin IV and Ampicillin SQ
10L Saline IV and Tulathromycin SQ
10L Lactated Ringers IV and Florfenicol SQ
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EVP Module 1 – October 2014
Case 1:
CASE DISCLOSURE #8
You keep the calf in the clinic overnight, and reassess him in the AM. You find the following:









Bright alert and responsive
Normal stool
Drinking water
Refuses grain but will eat some hay
RT: 104
RR 40 with some intercostal breathing
HR 40
Lung Sounds: Muted, harsh sounds on inspiration on the right hand side
Rumen contractions 0-1 per minute
13. You summarize this information as:
a. The pneumonia is advancing in severity and we need to add an additional antibiotic, his
prognosis is unchanged.
b. The pneumonia is resolving but his pleuritis is worse, his prognosis is worse.
c. The calf is successfully walling off the infection, his prognosis has improved.
d. The calf is responding as expected, rumen transfaunation is warranted, his prognosis is
unchanged.
The PCR from the deep nasal swab comes back with the following results:
POS: IBR, BVD1, BVD2, M. hemolytica
NEG; PI3, BRSV, BCV, M. bovis
14. Your response to these results is:
a. No changes
b. Vaccinate the calf with IBR vaccine
c. Treat the calf with Enrofloxacin
d. Vaccinate the calf with IBR vaccine and treat him with Enrofloxacin.
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EVP Module 1 – October 2014
Case 1:
CASE DISCLOSURE #9
Based on your experience you stay the course, don’t add any additional antibiotics and
transfaunate the bull. That night you look at the bull again and find:










Bright alert and responsive
Normal stool
Drinking water
Cleaned up all his hay
RT: 103.5
RR 35 with noticeable intercostal breathing
HR 40
Lung Sounds: Muted, harsh sounds on inspiration on the right side
Rumen contractions 1-2 per minute, evidence of cud chewing.
R/US: pleural effusion 2 cm below the elbow on the right side. No changes in lung.
15. Based on this you:
a. Change treatment to ampicillin BID and keep him another week at the clinic.
b. Call the owner and tell him that he can pick the bull up in the AM but he needs to re-treat
him with tulathromycin in 7 days for good measure.
c. Send the bull home with careful monitoring of his appetite.
d. Keep the bull in the clinic another week after draining the fluid on the right side of his
chest and infusing sodium ampicillin in the chest cavity.
e. Initiate a 2 month course of SQ Procaine Penicillin
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