Internet Use as a Tool for Veterinarians

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Internet Use as a Tool for Veterinarians

• Dr. Elaine Ong BVSc (Melb)
• Box Hill Veterinary Hospital
• Melbourne, Australia

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Internet Use for VetsBenefits

• Up to Date
• Networking with Specialist Colleagues
• Access to Journals Online Textbooks
• QAs in Vet Forums
• Continuing Education
• Free / Paid Sites

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Internet Use for VetsTraps Pitfalls

• Reliable Information
• Reliability
• Anecdotal / Untested
• Non-Vet Advice
• Company Websites
• Sales Websites
• Clients Also Using Internet Too!!
• Self Diagnosis
• Self Treatment!
• Self Education of Vet Dx

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Internet Use for VetsUniversity Government
Sites

• U of California (Davis)
• SA Cardiovascular Medicine
• Cases, ECG, Ascultation
• Colorado State U
• Diagnostic Imaging tutorials, cases, reviews
• SA Toxicology Online Text
• Aurburn University
• Species Exam Review

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Internet Use for VetsVIN.com (Vet Info Network)

• Largest paid veterinary online community!
• Full staff of Specialists on
• QA Case Message forums
• CE Courses
• Live Seminars
• Handouts
• Full Textbooks
• Full Drug Handbooks
• Online Calculators (CRI)
• Resources / Videos / Pics
• Vet to Vet
• Vet to Specialist
• Online Bookshop

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Internet Use for VetsVeterinaryPartner.com

• Website dedicated to Clients
• Education
• Handouts
• Compliance
• Developed by Vets (From Vin.com) Reliable
  Veterinary Info

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Internet Use for VetsIVIS.org (Intl Vet
Information Service)

• Full Textbooks Online
• SA Orthopaedics
• Infectious Diseases
• Behavior
• Dermatology
• SA Haematology
• Dentistry
• Blood Tranfusion
• Anaesthesia / Analgesia

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Internet Use for VetsBayerAccelerate.com.au

• Free CE Vet Courses from Australian Specialists
• 1-2Hrs / Course
• Printable Notes / Quiz / Videos

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Internet Use for VetsScholar.Google.com (Google
Scholar)

• Free Online Med/Vet Journal Search
• Great for Hard to Find topics / Obscure Species
• May have to pay for PubMed Articles

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Internet Use for VetsOther Helpful Sites

• Merck Veterinary Manual
• LA / SA Complete Reference
• ASPCA Animal Poison Control Centre
• Most Comprehensive Tox Site
• Animal Insides
• Radiology Techniques / Images

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Example Case 1Medical Case Management

• Hx
• Snoopy 5y MN DSH
• Recurrent Cystic Pads on Feet, Painful,
  Sanguinous Exudate
• VIN.com
• Dermatology Forum Board post Pics / Signalment
• Specialist gave Dx before Histopathology results!
• Result
• Plasmacytic pododermatitis
• Further discussion guided Treatment Prevention
• Links to other vets with same cases in Cats!

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Example Case 2Diagnostic Protocol Search

• Hx
• Amme 6m F G.Retriever
• Urinary Incontinent
• Relapsing UTI
• Unresponsive to Mgt
• VIN.com
• Review of UI online texts for DDx List (Inc.
  Ectopic Ureters)
• Online text Pictures of IVP Contrast Study Rad
  Protocol
• Result
• Dx Bilateral Ectopic Ureters
• Tx Refer to Specialist Surgeon

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Example Case 3Specialist QA

• Hx
• 3y Cat, Adopted as stray, no previous Vx Hx.
  Lifelong tremors and ataxia.
• Non-responsive to PB, Valium elevated liver enz /
  obese / polyphagia!
• VIN.com
• Post message to neuro board gave neuro exam form
  guide
• Reply w/DDx List
• Result
• Dx Cerebellar hypoplasia
• Tx Taken off medications and instituted long
  term supportive care and links for client to
  other CH cat owners.

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Respiratory Sounds Chart
Courtesy Dr Jill Maddison
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Case Management Example

• Example of good clinical exam
• Distinguishing prioritizing problems
• (multiple clinical signs)

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Devise Problem List

• History
• Clinical Examination

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History

• Two year old Chihuahua
• Obtained as a stray 3 months ago
• Not been examined by a veterinarian until now
• 3 day history of inappetance
• Lethargy
• Depression
• Intermittent vomiting
• Polydipsia
• Passing bloody urine for the past 2 days

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Clinical Examination

• - Very depressed
• Mucous membranes very pale
• Slightly jaundiced
• CRT of 2 secs
• Grade V/VI systolic heart murmur loudest
  tricuspid region
• Marked jugular pulse
• HR 120 PR
• Hepatomegaly
• Splenomegaly
• Mild anterior abdominal pain
• Rectal temperature 39.6 C
• Urine is a deep red colour

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Problem List

• - Heart murmur
• - Pale mucous membranes
• - Jaundice
• - Splenomegaly
• - Hepatomegaly
• - Haematuria 
• - Lethargy
• - Depression
• - Intermittent vomiting
• - Polydipsia

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Assessment

• - Very pale mm anaemia, shock or poor
  peripheral perfusion
• - Heart murmur , R side cardiac disease on
  RHS or anaemia causing haemic murmur
• - HR PR no pulse deficits no myocardial
  failure
• - Jaundice pre , hep or post hep disease
• - Hepatomegaly usually pre hep disease causing
  increased load or due to hepatic disease
• - Splenomegaly inc load haemolysis or
  splenic accident
• - Haematuria haemorrhage or haemolysis

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Initial Plan

• Initial diagnostics CBC, biochem
• Interim therapy - supportive

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Results of Diagnostics

• Laboratory results (reference values in
  brackets)
• PCV 0.30 L/L (0.37-0.55) Plasma
  appearance Heamolysed
• Uncorr. reticulocyte count 10 (corrected count
  4.5)
• Nucleated RBC 37/100 WBC Urinalysis SG 1.056
• Platelet count adequate few RBC
• Total plasma protein 73.0 g/L (55-75) supernate
  nt red
• WBC count all cells x 109/L 3 bilirubin
• Neutrophils 18.0 (4.0-9.4)
• Band neutrophils 0.7 (0-0.2)
• Lymphocytes 0.5 (0.9-3.6)
• Monocytes 1.1 (0.2-1.0)
• Eosinophils 0.5 (0.1-1.2)
• RBC morphology 2 polychromasia, 2 anisocytosis,
• 2toxic neutrophils
• occasional fragmented RBC (shistocytes)
• Serum albumin 28 g/L (22-35)

• Essential Questions
• Anaemia regen or non-regen
• Plasma protein normal no haemorrhage
• Stress leukogram
• AP and ALT mildly elevated not hep disease or
  post hep disease
• Urine with haemolysed blood haemolysis or
  hepactic thrombosis
• RBC morphology microangiopathic haemolysis
•  

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LCPS Approach

• Pathophysiology
• Differential diagnosis

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Revised Assessment

• Pathophysiology
• Regenerative anaemia due to intravascular
  microangiopathic haemolysis of rbc (blood,
  urine) jaundice
• Causes of IMH
• DIC
• Caval syndrome
• Splenic torsion
• Splenic haemangiosarcoma
• Tricuspid murmur ansd jugular pulse
• No hep or post hep disease
• No haemorrhage
• No coag disorder
• DDX
• AIHA( but not usually see schistocytes)
• Drug toxicities
• eg paracetomol, sulfa drugs (does not explain
  heart murmur/jugular pulse?)
• Ticks babesia can cause IVH and EVH as above
• Caval syndrome in view of RHS murmur
• Snake bite ( no cardiac signs)

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Diagnosis

• Heart Worm Disease
• Caval Syndrome

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Additional Resources
Source www.iris-kidney.com
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Additional Resources
Source www.iris-kidney.com
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Case 5 Siamese Cat
Example of pattern recognition interpretation
of lab results Multiple signs multiple blood
test abnormalities
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Case 5 Siamese Cat

• History
• A 17 year old female (desexed) Siamese cat is
  presented with a 3 week history of anorexia. She
  intermittently vomits bile-stained material. She
  is depressed and has been drinking a lot more
  water than previously.
• Physical Examination Findings
• The cat is depressed and lethargic. Her sclera
  and mucous membranes are jaundiced and she is
  approximately 5 dehydrated. HR 160, rectal
  temperature 39.7 C. She has a dull and ill
  kempt hair coat and is quite thin. Abdominal
  palpation reveals slightly small kidneys. Her
  thorax auscultates normally.

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Assessment Siamese Cat

• History A 17 year old female (desexed) Siamese
  cat is presented with a 3 week history of
  anorexia. She intermittently vomits bile-stained
  material. She is depressed and has been drinking
  a lot more water than previously.
• INITIAL PROBLEM LIST
• Anorexia
• Intermittent vomitting
• PD
• Jaundice
• fever
•  
• INITIAL ASSESSMENT
• Chronic anorexia- chronic disease
• Vomitting unrelated to eating secondary GI prob
• Jaundice pre hep, hep or post hep
• Dehydration- from lack of intake and losses from
  vomitting
• INITIAL PLAN
• Blood and UA
• IV fluids- maintenance plus dehydration and
  losses plus Potassium

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Results of Diagnostic Procedures

• Laboratory results (reference values in
  brackets) Urinalysis
• PCV 0.25 L/L (0.25-0.45) SG 1.055
• Uncorrected reticulocyte count 1 pH 6
• Total plasma protein 95.0g/L (55-75) 2
  bilirubin
• WBC count all cells x 109/L 2 glucose
• Neutrophils (segmented 20.0 (4.0-9.4) -ve
  ketones
• Band neturophils 2.2 (0-0.3) 2 protein
• Lymphocytes 2.0 (0.9-3.6)
• Monocytes 3.5 (0.2-1.0)
• Eosinophils 0.6 (0.1-1.2)
• Serum albumin 30 g/L (22-35)
• Globulin 55 g/L (22-45)
• ALT 200 U/L (
• ALP 55 U/L (
• Amylase 1,000 U/L (
• Urea 25 mmol/L (2-10)
• Creatinine 300 µmol/L (40-120)
• Glucose 14.5 mmol/L (3.3-7.0)

• RESULTS
• Mod anaemia( consider dehydration)
• Poorly Regenerative
• Neutrophilia with left shift, monocytosis
• Hyperglob dehydration or inflammation
• High TP- dehydration and hyper Glob
• Pre renal azotaemia as usg 10.50
• Bilirubinaemia
• Bilirubinuria
• Hyperglycaemia and glusocuria-prob stress - not
  high enough and not ketotic- cat too sick
• Conjug and unconjug bilirubinaemia
• Mod elevation ALT- AP nromal

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Assessment Siamese Cat

• REVISED ASSESSMENT
• Rule out Pre hep jaundice
• -due to haemorrhage or haemolysis amd anaemia is
  regen by 48 hours
• This case is hepatic jaundice ALT significantly
  high- in cats
• Rule out other causes of non regen anemia eg.
  renal disease, FIV felv
• Types of liver disease in cats (new
  classification)
• Lymphocytic cholangiohepatitis
• Neutrophilic cholangiohepatitis
• Lymphoma
• Hepatic lipidosis ( AP HIGH)
•  
• Dx Neutrophilic cholangiohepatitis
• - and pancreatitis
•  
• TX FOR LIVER DISEASE ( GENERAL)
• Atb
• Feeding
• Denosyl

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Case 6 Labrador Cross

• Example of listing prioritizing a problem list
• A good clinical exam

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Case 6 Labrador cross

• History
• A 10 year old female (desexed) Labrador cross
  presents with an acute history of sudden collapse
  while exercising in the park 2 days ago. Prior
  to this time the dog had seemed normal in all
  respects. The episode of collapse did not appear
  to involve loss of consciousness. After
  collapsing, the dog remained weak for several
  hours but gradually recovered and seemed fairly
  normal the next morning. However the own has
  since noticed that the dog is unwilling to
  exercise and tires easily.
• Physical Examination Findings
• The mucous membranes are moderately pale. A
  pulse deficit is detected (HR 160, PR 120).
  Abdominal palpation is difficult as the dog is
  quite overweight but no obvious abnormalities are
  present. Rectal temperature is normal. Thoracic
  auscultation reveals ectopic cardiac beats.

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Assessment Labrador cross

• INITIAL PROBLEM LIST
• Collapse
• Exercise intolerance
• Pale mm
• Pulse deficit of 40
•  
• INITIAL ASSESSMENT
• Episodic collapse induced by exercise
• - conscious so not seizure or syncope
• - is an episodic weakness
• Consider
• NM dysfunction (M gravis- but no other signs)
• CVS dysfunction (pulse deficits)
• Metabolic (hypo Ca, hyper Ca, hypo G, hyper/hypo
  K)
• Myopathy
• Respiratory( laryngeal paralysis, HWD)
• Exercise intolerance- all of the above
• Pale mm- suggest peripheral perfusion
• Cardiac arrhythmia- likely CVS

History A 10 year old female (desexed)
Labrador cross presents with an acute history of
sudden collapse while exercising in the park 2
days ago. Prior to this time the dog had seemed
normal in all respects. The episode of collapse
did not appear to involve loss of consciousness.
After collapsing, the dog remained weak for
several hours but gradually recovered and seemed
fairly normal the next morning. However the own
has since noticed that the dog is unwilling to
exercise and tires easily.
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Results of Diagnostic Procedures

• ECG results Causes
• MULTiform VPCS and tall T Cardiac- neoplasia,
  HWD Myocarditis, drugs etc.
• Ventricular tachycardia Extra cardiac- anaemia,
  splenic haemangiosarcoma, pancreatitis,
  sepsis, uraemia, GDV etc.

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Results of Diagnostic Procedures (cont.)

• Laboratory results (reference values in
  brackets)
• PCV 0.30 L/L (0.25-0.45)
• Total plasma protein 68.0 g/L (55-75)
• Nucleated RBC 10/100 WBC
• Reticulocytes 15 (uncorr.)(10)
• WBC count all cells x 109/L
• Neutrophils 25.5 (4.0-9.4)
• Band neutrophils 0.3 (0-0.24)
• Lymphocytes 3.0 (0.9-3.6)
• Monocytes 0.9 (0.2-1.0)
• Eosinophils 0.3 (0.1-1.2)
• RBC morphology 3 anisocytosis, 2 macrocytosis
• 3 polychromasia, 3 Heinz bodies
• 1 spherocytosis
• ALT 69 U/L (
• ALP 67 U/L (

• RESULTS
• REGEN anaemia
• Neutrophilia left shift
• RBC with regen, HZ bodies
• Spherocytes
• Biochem normal, no HWD

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Assessment Labrador cross

• REVISED ASSESSMENT
• Regen anemia with spherocytes and HZ bodies
• Cardiac arrythimias
•  
• Dx
• Haemangiosarcoma

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Case 7 Kelpie Pup

• Example of pattern recognition
• History can be misleading

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Case 7 Kelpie Pup

• History
• A seven month old unvaccinated kelpie pup was
  presented because of extreme depression,
  inappetance and uncharacteristic unwillingness to
  work for 24 hours. He was tied up near a shed
  with a rat problem and may have had access to rat
  bait. The pup was wormed regularly.
• Physical Examination Findings
• Mucous membranes were extremely pale. There
  were several small petechial haemorrhages on his
  penis. Rectal temperature was 39.1 C. Dark
  tarry faeces were passed in the examination room.
  HR PR 160.

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Assessment Kelpie Pup

• INITIAL PROBLEM LIST
• Extreme depression
• Inappetance
• Lethargy
• Suspect rat poison
• CLINICAL EXAM
• Very pale mm
• Petechial haemorrhage on penis
• Dark tarry faeces
• INITIAL ASSESSMENT
• Pale mm - anaemia , shock or poor peripheral
  perfusion
• Tachycardia but hrpr no pulse deficits - rule
  out myocardial disease
• Poetechia platelet dysfunction or deficiency
• Tarry faeces malaena primary bleeding from
  mucosa, (endoparasites, GIT ulcers, tumours,
  secondary bleeding (eg. coag disorders) and self
  ingested blood (eg. oral nasopharyngeal
  pulmonary lesions))
• PLANS
• PCV

History A seven month old unvaccinated kelpie
pup was presented because of extreme depression,
inappetance and uncharacteristic unwillingness to
work for 24 hours. He was tied up near a shed
with a rat problem and may have had access to rat
bait. The pup was wormed regularly.
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Results of Diagnostic Procedures

• Laboratory results (reference values in
  brackets)
• PCV 0.08 L/L (0.37-0.45)
• MCV 74 fL (63-74)
• MCH 19 pg (20-26)
• MCHC 26 g/dl (31-36)
• Uncorrected reticulocyte count 21.8 (corrected
  3.9 )
• Total plasma protein 33.0 g/L (55-75)
• Platelet count 30 x 109/L (200-500)
• WBC count all cells x 109/L 10.9 (8.0-17.0)
• Neutrophils 6.1 (4.0-9.4)
• Lymphocytes 2.4 (0.9-3.6)
• Monocytes 0.2 (0.2-1.0)
• Eosinophils 2.2 (0.1-1.2)
• RBC morphology Anisocytosis
• Poikilocytosis
• Polychromasia
• Hypochromasia

• RESULTS
• Severe Regen anemia
• - corrected retric count 3.9
• Low PP haemorrhage
• Thrombocytopenia-
• Eosinophilia- parasitic
• Coag Normal
• RBC morphology indicate Regen but may be iron
  deficient

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Assessment Kelpie Pup

• REVISED ASSESSMENT
• Severe regen anemia due to haemorrhage
• Haemorrhage due to thrombocytopenia
• CAUSES
• Dec Prod
• Inc destruction
• Inc sequestration
• Inc utilization
• IMT- very common
• Ticks babesia, erlichia
•  
• Dx
• IMT and HOOKWORM