ACVECC Small Animal Residency Training Benchmark
November 2010
A 5-year old female Rottweiler weighing 42kg was referred to your hospital for
vomiting of two days’ duration. Her past medical history is benign. Her physical
examination reveals a dog with a good body condition and hair coat. She is
approximately 5% dehydrated and splints somewhat on dorsal abdominal palpation.
There are no other abnormalities.
Blood biochemistry results:
Glucose: 96 mg/dL (60 – 115)
5.33 mmol/l (4-6)
Sodium: 132 mmol/L (139 – 150)
Potassium: 4.9 mmol/L (3.4 – 4.9)
Chloride: 102 mmol/L (106 – 127)
Phosphorous: 15.1 mg/dL (2.9 – 5.3)
5.01 mmol/l (0.9-1.7)
Total Protein: 4.9 g/dL (5.5 – 7.5)
49 g/l (55-75)
BUN > 200 mg/dL (10 – 29)
>71.4 mmol/l (3-10)
Creat: 13.9 mg/dL (0.6 – 1.6)
1229 umol/l (70-130)
ALT: 18 IU/L (10 – 120)
ALP: 15 IU/L (0 – 140)
Basic Complete Blood Count results:
WBC: 11,100 (6000 – 17,000) / uL
11.1 x109 /l (6-17x109)
HCT: 54% (37 – 55)
PLT: 314,000 (200,000 – 500,000) / uL
314 x109 /l (200-500x109)
Urinalysis:
SpGr: 1.013
Protein: 500 mg/dL
pH: 6.0
Gluc: neg
Ketones: neg
Bili: neg
Blood: 2+
Sediment: See image below
Abdominal radiographs show no abnormalities.
1. What is the large structure seen in the urine sediment?
2. Give this dog’s extended problem list
3. This dog has evidence of renal failure.
a.) Is this more likely acute or chronic?
b.) Explain your rationale for this diagnosis using at least one piece of
information from the history, physical exam, and each diagnostic procedure
listed above.
4. Please list at least 5 broad categories of possible predisposing causes for this
dog’s renal failure. Please list at least three examples under each category.
5. What diagnostic tests could be performed to help determine the etiology of acute
renal failure in the dog? Prioritize these tests into first tier (would recommend on all
patients with renal failure), second tier (will recommend on many cases based on
results of first tier, geographic location, or other indications), and third tier (will only
recommend if indicated based on results of other tests)
a. First tier
b. Second tier
c. Third tier
6. Design a specific preliminary treatment plan (fluid therapy and other treatments)
for this patient. What are some concerns in this patient regarding fluid therapy?
Design a preliminary monitoring plan while pending diagnostic test results. Explain
your rationale for each.
Fluid therapy:
Concerns for fluid therapy:
Medications:
Monitoring:
7. You place a urinary catheter to measure her urine output.
a. What conditions must be met prior to making a diagnosis of pathologic
oliguria or anuria in this patient?
b. What is normal urine output?
c. What is the definition of oliguria?
d. What is the definition of anuria?
e. What is the definition of polyuria?
8. Below is a list of medications that can be used in acute renal failure to potentially
increase urine output. List the different mechanisms of action for each
medication and the possible adverse effects that it may cause.
a. Diltiazem
i. MOA
ii. Adverse effects
b. Lasix (Furosemide)
i. MOA
ii. Adverse effects
c. Mannitol
i. MOA
ii. Adverse effects
d. Dopamine (<5mcg/kg/min)
i. MOA
ii. Adverse effects
e. Fenoldopam
i. MOA
ii. Adverse effects
9. Please describe the difference between peritoneal and intermittent hemodialysis in
the following areas. (10 points)
a. Dialysate preparation and composition
b. Anticoagulation
c. Ultrafiltration
d. Blood pump mechanism
e. Exchange surface
10. List four potential complications of peritoneal dialysis:
11. List four potential complications of hemodialysis:
12. Please answer the following questions regarding Continuous Renal
Replacement Therapy
a. What is the definition and purpose of CRRT?
b. List and describe the four different possible modes of operation in CRRT.
c. What are some potential advantages of CRRT over intermittent
hemodialysis and peritoneal dialysis? What are some potential
disadvantages?
Please answer the following questions regarding Ethylene Glycol toxicity
13. What is the minimum lethal dose of ethylene glycol that has been reported in
dogs and cat?
14. List in order the 5 major metabolites of ethylene glycol that develop after
ingestion
15. Which metabolite is the most nephrotoxic?
16. List diagnostic tests or measurements that can be used to support a diagnosis of
ethylene glycol toxicity?
17.
List the mechanisms by which isosthenuria occurs in ethylene glycol toxicity.
A 6 year old 9 kg MC DSH presents for a 3 day history of progressive lethargy and
intermittent vomiting. The cat stopped eating approximately 4 days ago, shortly
after the owner left town (the cat is presented by the pet sitter). On physical
examination, the cat is mentally depressed, body condition score 8/9, temperature
99.2°F (37.3°C), pulse rate 168/min, rate 28/min, mucous membranes pale pink
and icteric, capillary refill time 1.5 sec, with moderate and synchronous pulses. The
abdomen is difficult to palpate due to the obesity, but there is probable cranial
organomegaly.
Complete Blood Count
RBC
7.01 x 106/uL
(5.0-10.0)
HBG
10.4 g/dL
(9.8-15.4)
HCT
31.5%
(30-45%)
MCV
44.9 fl
(40-55)
MCH
14.9 pg
(13-17)
MCHC
33.2 g/dL
(30-36)
Platelets est: adequate, some clumps
WBC
18.7 x 103/uL
(5.5-19.5)
Segs
14.3 x 103/uL
(3.5-12.5)
3
Bands
0.36 x 10 /uL
(0-0.3)
Lymphs
3.26 x 103/uL
(1.5-7.0)
3
Monos
0.18 x 10 /uL
(0-0.9)
Eos
0.00 x 103/uL
(0-0.2)
3
Baso
0.00 x 10 /uL
(0-0)
Chemistry Screen
Glucose
125 mg/dL
BUN
4 mg/dL
Creatinine 0.8 mg/dL
Phosphorus 4.2 mg/dL
Calcium
10.1 mg/dL
Sodium
150 mmol/L
Potassium 4.6 mmol/L
Chloride
114 mmol/L
Total Protein 6.1 g/dL
Albumin
2.8 g/dL
ALP
969 U/L
ALT
199 U/L
GGT
4 U/L
T. Bili
7.5 mg/dL
Cholesterol 201 mg/dL
(65-112)
(20-34)
(0.9-1.8)
(3.6-6.0)
(9.8-11.7)
(149-156)
(3.6-4.9)
(113-125)
(6.0-7.7)
(3.0-4.3)
(14-50)
(31-104)
(0-4)
(<0.2)
(128-147)
6.94 mmol/l
1.43 mmol/l
70 umol/l
1.36 mmol/l
2.53 mmol/l
(4-6)
(3-10)
(80-130)
(0.9-1.8)
(2.3-2.8)
61 g/l (60-77)
28 g/l (30-43)
128.3 umol/l (0-3)
5.21 mmol/l (2.3-4.3)
Urinalysis (table top)
Color: yellow, hazy
USG
1.011
pH
7.5
protein
neg
glucose
neg
ketone
neg
bilirubin
large
blood
negative
Sediment: 0 RBC, 0 WBC, few bilirubin crystals
Few squamous epithelial cells
Coagulation Screen
PT
8.5 sec
aPTT
12.8 sec
(8.2-11.4)
(11.6-18.4)
18.
What is the most likely diagnosis?
19.
Describe the normal production, catabolism and excretion of bilirubin.
20.
Bile salts are reabsorbed in which of the following locations?
a.
b.
c.
d.
e.
21.
Duodenum
Jejunum
Ileum
Cecum
Colon
Where and how is albumin produced and how is its production regulated?
22. Calculate RER for this patient.
23. Describe in detail the procedure to properly place an esophagostomy tube.
24. Please list three (3) advantages and one (1) disadvantage of esophagostomy
tube placement:
25. Please list at least four potential complications of esophagostomy tube use
or placement:
26. Justify the use each of these medications in the management of a patient with
hepatic lipidosis:
a. L-carnitine
b. Taurine
c. Ursodeoxycholic acid
d. Silymarin
e. s-Adenosylmethionine
f. Thiamine and Cyanocobalamine
g. Vitamin K1
h. Vitamin E
27. Which ONE of the following decreases the activity of hormone-sensitive
lipase?
a.
b.
c.
d.
Growth hormone
Insulin
Thyroxin
Epinephrine
28. Which ONE of the following is NOT a requirement for the formation of very
low-density lipoproteins (VLDL) particle dispersal?
a.
b.
c.
d.
Transport of the particle out of the hepatocyte into the perisinusoidal space
Intact lipid transport through subcellular compartments
Formation of a secretory particle
Particle combination with pro-adipose
29. List the mechanism of action for each of the following anti-emetics:
a. Maropitant
b. Phenothiazines
c. Metoclopramide
d. Ondansetron and Dolasetron
30. Ammonia is one of the key participants in hepatic encephalopathy. In cats
hyperammonemia can develop in the absence of liver disease or porto-systemic
shunt due to limited reserves in which essential amino acid?
a. Tryptophan
b. Glutamine
c. Arginine
d. Leucine
31. Describe the effects of ammonia on the brain.
32. Discuss the benefits of using the following therapeutics in patients with hepatic
encephalopathy
a. Mannitol
b. Lactulose
c. Rifaximin
d. Flumazenil
33. Discuss how the following 4 factors can contribute to the severity of hepatic
encephalopathy
a. Inflammation
b. Gastrointestinal hemorrhage
c. Hypokalemia
d. Metabolic alkalosis