Showing posts with label Conclusion Caturday. Show all posts
Showing posts with label Conclusion Caturday. Show all posts

Saturday, February 17, 2024

Conclusion Caturday: Vince Vomits Valiantly (Case 7)

Picture of stuffed alpaca Professor Pocky and stuffed camel Douglas

Photo of TA Douglas (Left) and Professor Pocky (Right) taken by Dr. Haus
 

Click For Explanation of Case Flow

 

Click for Test Case Tuesday:  Vince Vomits Valiantly

 

Click for Thoughtful Thursday:  Vince Vomits Valiantly

 

Quick Review


Diagnosis:

🦴Myasthenia Gravis🦴

 

Pathophysiological Point:

Myasthenia gravis is a disease where the acetylcholine receptors between nerves and muscles are destroyed or blocked.  Simply, nerves cannot conduct their signals to muscles.  Muscles are unable to contract (move) without the signals from the nerves.

 

 Questions, Answers, and Further Information:

 

Level 1 Questions, Answers, and Further Information:

  1. Vince's communication between his nerves and muscles is disrupted, how does that affect the muscles of his body?  Why?

    If Vince's nerves cannot communicate with his muscles, his muscles will not be able to move.  The nerves tell the muscles to move and without this signaling he will not be able to contract his muscles easily leading to difficulty moving.

  2. What part of Vince's history and physical exam findings support the diagnosis of a disease that affects communication between the nerves and muscles of his body?

    The history and physical exam findings that support his diagnosis are the generalized weakness and muscle loss.  These findings support the fact that Vince's nerves are not able to send their normal signals to the muscles.

  3. Challenge question, why does Vince have megaesophagus?  How does this cause regurgitation after meals?  (HINT:  Think about Vince's disease and how it would affect the muscles of the esophagus)

    The esophagus is a muscle much like the other muscles of the body.  In order for food and fluid to get to the stomach, the esophagus must be able to contract.  With Vince's disease, he cannot use his esophageal muscles to push the food/fluid down to his stomach so the food and fluid accumulates in the esophagus causing it to expand and stretch causing megaesophagus.  As this food/fluid builds up in the esophagus it will comes out the mouth because the muscle contractions are not there to get the food and fluid to his stomach efficiently.

    Helpful Links:

 

Level 2 Questions, Answers, and Further Information:

  1. How does myasthenia gravis cause disease (i.e., megaesophagus) in a patient?  Be sure to mention the “normal” esophageal physiology in your answer and explain physiologically where the miscommunication is occurring.  (HINT:  Review normal neuromuscular junction physiology)

    Myasthenia gravis destroys/blocks the acetylcholine receptors on the muscle cells.  Neurons release acetylcholine into the synaptic cleft at the neuromuscular junctions.  This allows the muscle cell to begin to undergo the process of depolarization which will eventually lead to the muscle contracting.  The esophagus is a muscle that must contract to move food/fluid towards the stomach.  With the acetylcholine receptors of the esophageal muscles destroyed/blocked, the esophagus cannot move the food/fluid and the esophagus will expand to accommodate all the stuck food/fluid material.

  2. How does megaesophagus lead to Vince’s major clinical sign (regurgitation)?  (HINT:  Think about what keeps us from floating away into space)

    Since Vince cannot contract his esophagus, the food/fluid will sit in the esophagus unable to move aborally.  This leads to the material falling back out the mouth especially when Vince puts his head down as gravity will cause the food/fluid to fall out of the mouth.

  3. Challenge question, explain why Vince has pneumonia.  Be sure to explain how his underlying disease predisposed him to this condition.  Be sure to mention the anatomy involved.  (HINT:  Think about what structure sits right next to the esophagus)  

    Vince's pneumonia is likely due to his regurgitation from the megaesophagus.  Each time Vince regurgitates his food, he risks some of the food/fluid accidentally falling into the trachea which sits next to the esophagus.  When food/fluid enters the esophagus there is a risk that the material gets into the deeper lung tissues leading to pneumonia (inflammation of the alveoli).

    Helpful Links:

Level 3 Questions, Answers, and Further Information:

  1. Describe the treatment plan you would recommend Vince and why you are recommending each part of your treatment plan.  Please answer this question as if you are speaking to a professional colleague.  .

    Vince's treatment plan will depend on the etiology of his disease.  If Vince's disease is due to a thymoma the thymoma needs to be surgically removed.  Otherwise, anti-acetylcholinesterase medications can be used to treat these patients.  Vince will also need to be treated for his pneumonia with antibiotics and other supportive care as needed.

  2. Describe your recommended treatment plan and why you are recommending each part of your treatment plan.  Please answer this question as if you are explaining it to a client/patient without a scientific background.

    Vince has a disease that causes his nerves and muscles to not communicate correctly.  We will be starting Vince on a medication that will help his nerves and muscle communicate better while also starting him on antibiotics to treat his pneumonia.

  3. Please describe the different ways Vince's owners could help manage his condition with environmental changes.

    There are a few ways Vince's owners can help increase Vince's quality of life at home.  Firstly, Vince should be fed and watered from dishes that are elevated off the floor (less gravitational effects).  The owners can also hold Vince up vertically after meals to help gravity "push" the food/fluid down to his stomach.  His owners should also feed him smaller, more nutrient dense meals to decrease his risk for regurgitation.

    Helpful Links:


Day 3 Conclusion

I hope you enjoyed the Vince's case!  Don't forget to...

📚 Review material related to the goats' case 

🤩 Get excited for upcoming cases

 

Dr. Haus's Unsolicited Life Advice: Don’t trust a history at face value - terms can be misused

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Saturday, February 10, 2024

Conclusion Caturday: Janice is Jinxed (Case 6)

Picture of stuffed alpaca Professor Pocky and stuffed camel Douglas

Photo of TA Douglas (Left) and Professor Pocky (Right) taken by Dr. Haus
 

Click For Explanation of Case Flow

 

Click for Test Case Tuesday:  Janice is Jinxed

 

Click for Thoughtful Thursday:  Janice is Jinxed 

 

Quick Review


Diagnosis:

🐮Ketosis🐮

 

Pathophysiological Point:

Ketosis is a condition where the body is breaking down fats at an extremely elevated rate due to a negative energy balance.  This energy imbalance occurs because the body is using more energy than it is taking in through eating.

 

 Questions, Answers, and Further Information:

 

Level 1 Questions, Answers, and Further Information:

  1. Why do you think Janice is suddenly breaking down more fat?  In other words, why would Janice have a negative energy balance?  (HINT:  Think about Janice's history and physical exam findings)

    Janice is in a negative energy balance and breaking down more fat because she recently had her calf and is producing a large amount of milk.  In addition, Janice has a high body condition score (BCS) and thus has more fat in her body than an animal with a normal BCS.  It takes a lot of energy to make milk and Janice needs A LOT more energy to make milk for her baby (lactation).

  2. What is the pathway that is occurring at an increased rate in Janice's body?  Please write out all the steps of the process and include what molecule there will be more of in Janice's bloodstream.  (HINT:  Click here)

    The process that is happening at an increased rate in Janice is gluconeogenesis of fats.  In this process, the body is breaking down the adipose tissue (fat tissue) into glycerol and fatty acids.  The glycerol is used to produce glucose for the body while the fatty acids accumulate and are converted to ketones.  Due to this, Janice will have more ketones in her bloodstream (her glucose will be taken out of the bloodstream very quickly to make more milk).

  3. Challenge question, what information in Janice's history AND physical exam findings put her at increased risk for developing ketosis?  Why do those factors increase her risk for ketosis?  What ways could the farmer have reduced Janice's chance for developing ketosis?  (HINT:  Think about the underlying cause of the disease in Janice's case)

    Janice was at increased risk to develop ketosis due to her birthing a calf and because she was overweight before having the calf.  Having a calf puts Janice at increased risk for developing ketosis because after having the calf Janice needs to produce a large amount of milk.  This causes most of Janice's energy (glucose) to go to her milk and her body will start to break down fats to provide enough energy to produce milk and to keep herself alive.  Janice being overweight is another factor because since Janice is so overweight her body can/will break down a large amount of fat meaning she will produce a large amount of ketones.  The farmer should make sure their cows are not overweight prior to having their calves to decrease the risk of ketosis.

    Helpful Links:

 

Level 2 Questions, Answers, and Further Information:

  1. Explain why Janice has low glucose concentrations and high ketone concentrations in her bloodstream.  Do not forget to name the process that is occurring at an increased rate in Janice's body and the steps of this process.  (HINT:  Click here)

    Janice has low glucose concentrations in her bloodstream because her body needs more energy than she is taking in by eating to undergo lactation.  In this case, her body is mobilizing fats through the process of gluconeogenesis.  In this process, her adipose tissue is broken down into fatty acids and glycerol.  That glycerol will be used in gluconeogenesis to produce the glucose Janice's body needs to produce the milk and keep her body functioning.  The fatty acids will accumulate and be processed into ketones.  This leads to the high ketone concentration in her bloodstream.  This process is called gluconeogenesis of fats.

  2. High ketone concentrations in the bloodstream lead to inappetence.  How does this information affect Janice's disease process?  (HINT:  Think about how inappetence is affecting Janice's body and her ability to overcome this disease process)

    Janice has high ketones in her bloodstream and since ketones decrease appetite Janice does not feel like eating.  The less Janice eats, the more fats she needs to break down.  In this way, the ketones are causing her ketosis to become worse and worse as her body breaks down fats, makes her more inappetent, and thus makes her body break down even more fats.  Janice is stuck in a loop that is making her get more and more sick.

  3. Challenge question, explain why ketosis is very common in dairy cattle, more common in dairy cattle that birth twins, and more common in dairy cattle that are overweight.  (HINT:  Think about what dairy cattle were bred to do and the underlying cause of this disease)   

    Ketosis is common in dairy cattle because they are bred to produce HUGE amounts of milk.  Due to this, a dairy cow's body will keep producing huge amounts of milk even if she is not eating enough food to sustain her body and milk production.  This process is also more common in dairy cattle that have twins because the birthing process of having twins uses much more energy than birthing one calf and more milk will be needed to support both calves.  Lastly, overweight dairy cattle are at an increased risk because they have a large amount of fat that can be broken down after they birth their calf and this will lead to them breaking down a higher amount of fat thus increasing the high ketone concentration in their bloodstream.

    Helpful Links:

Level 3 Questions, Answers, and Further Information:

  1. Describe the treatment plan you would recommend Janice and why you are recommending each part of your treatment plan.  Please answer this question as if you are speaking to a professional colleague.

    Janice has ketosis and needs to be treated with intravenous glucose to start the process of getting enough glucose in her bloodstream to "break" the ketosis cycle.  After this first IV dose, Janice should be drenched with oral propylene glycol which will provide her extra glucose until her body adjusts to having enough energy for both mother and calf.

  2. Describe your recommended treatment plan and why you are recommending each part of your treatment plan.  Please answer this question as if you are explaining it to a client/patient without a scientific background.

    Janice is suffering from a condition called ketosis.  Since Janice had her calf she has been needing a huge amount of extra energy to produce milk and started breaking down her fats for energy.  Unfortunately, Janice has broken down too much fat and it has caused her to get sick.  We need to give her extra energy/sugars in order to help her body adjust to producing milk and keeping her body healthy.

  3. Please create and describe a ketosis prevention plan for this farm to decrease the incidence of ketosis on this farm (both clinical and subclinical ketosis).  Explain the importance of subclinical ketosis and why it is extremely important to prevent this disease process on dairy cattle farms.

    There are a lot of answers to this question and I will list some here.  The biggest factor to decrease the risk of ketosis in your herd is to ensure that you are not overfeeding your cows and to make sure they remain in the correct weight range before giving birth.  Additionally, cattle should be monitored closely for ketosis after they give birth.  Cows that recently calved should all be kept in a pen together (often called the fresh pen) to get examined everyday and to have their blood ketone levels tested on an as needed basis.  It is also important to ensure that you are feeding your cattle appropriate nutrition for each stage of their lifecycle to ensure they are getting the nutrition they need at each stage of their lives.

    Helpful Links:



Day 3 Conclusion

I hope you enjoyed the Janice's case!  Don't forget to...

📚 Review material related to the goats' case 

🤩 Get excited for upcoming cases

Dr. Haus's Unsolicited Life Advice: Monitor Nutrition Closely

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Saturday, November 25, 2023

Conclusion Caturday: Sick Swinehaus Swine (Case 5)

Picture of stuffed alpaca Professor Pocky and stuffed camel Douglas

Photo of TA Douglas (Left) and Professor Pocky (Right) taken by Dr. Haus
 

Click For Explanation of Case Flow

 

Click for Test Case Tuesday:  Sick Swinehaus Swine

 

Click for Thoughtful Thursday:  Sick Swinehaus Swine 

 

Quick Review


Diagnosis:

🐽African Swine Fever🐽

 

Pathophysiological Point:

African Swine Fever (ASF) is an extremely fatal viral disease of domestic swine.  The ASF virus mostly infects the macrophages/monocytes of the pigs.  This causes a huge depletion in the immune cells of the animals.  The presentation of ASF is similar to Ebola in humans where the pigs have high fevers and start bleeding from different orifices.

 

 Questions, Answers, and Further Information:

 

Level 1 Questions, Answers, and Further Information:

  1. Explain why the veterinarian contacted the state veterinarian to report the disease outbreak.  (HINT:  Think about the severity of the pigs sickness and the information given at the start of this post).  

    The veterinarian contacted the state veterinarian to report a suspected foreign animal disease case.  When a large amount of animals die showing concerning signs the state veterinarian needs to be notified to ensure samples are taken to quickly diagnose the disease.  If the disease is a threat to other animals and the country we need to diagnose it quickly to contain the outbreak.

  2. Explain why the pigs are dying so quickly.  (HINT:  Think about the physical exam findings and the major finding that was found in the dead pigs' autopsies/necropsies)

    The pigs are dying quickly because they are bleeding from their noses, mouths, and other orifices.  When too much blood is lost, there is not enough oxygen getting to the cells of the body and the pig cannot survive without oxygen from the blood.

  3. Challenge question, what do you think should be done on the farm now that African Swine Fever has been diagnosed?  (HINT:  This disease is 100% fatal in American domestic pigs, there is no vaccination, the disease has never been on American soil, and there is no way to treat this disease.  The full answer to this question will be multiple different approaches)

    There are multiple answers to this question that are noted below:
    1. The pigs on the farm will need to be humanely euthanized as they have all been exposed to the disease
    2. The farm will need to be put on a strict quarantine where nothing can come in or out from the farm (this will help stop disease spread)
    3. The farm will be decontaminated by folks trained in disease outbreaks to remove the virus from the farm
    4. Surrounding farms will be put on quarantine and be tested for ASF
    5. There will be an investigation into the source of the infection

    Helpful Links:

 

Level 2 Questions, Answers, and Further Information:

  1. Affected pigs are showing the signs of redness throughout their skin.  The severe redness noted in these pigs tells us that they are undergoing what process at an increased rate?  (HINT:  The other signs of this process are heat, swelling, pain, and loss of function)

    The process that is occurring at an increased rate in the pigs is inflammation/the inflammatory process.

  2. Pathophysiologically explain the steps of the above disease process that leads to redness in these pigs.  Be sure to mention all molecules, substances, and changes that occur in each step.

    During the acute inflammation process, histamine is released and leads to a vasodilation of the blood vessels around the injury site while also increasing the leakiness of the vessels around the injury site.  The increased vasodilation brings more blood to the area of injury (increasing healing factors) and the increased leakiness allows more fluid, immune cells, etc. to enter the injury site to assist with healing.

  3. Challenge question, explain how African Swine Fever is similar to the Ebola virus in humans.  Be sure to note the pathophysiology, source of infection, physical exam findings, etc. that are similar between the two diseases.  (HINT:  For this one take the time to find reputable sources to learn more about each disease)

    There are many answers to this question.  Both diseases are from viruses that are able to spread easily between different hosts.  Clinical signs can be similar between the diseases (hemorrhagic fevers, gastrointestinal signs, rapid death, etc.).  Ebola virus also infections the monocytes/macrophages of the host.  And many more!

    Helpful Links:

Level 3 Questions, Answers, and Further Information:

  1. Describe your recommended plan and why you are recommending each part of your plan.  Please answer this question as if you are explaining it to a the farmer or the general public without a scientific background.  (Remember, this will be a sensitive conversation for most folks)

    In this situation, depopulation of the pigs on the farm will be required.  This is a sensitive topic as the farmers will likely have an emotional attachment to their animals, farm, and business.  In this case, it is important to speak empathetically with the farmers and addressing their feelings on having their livelihood and animals euthanized.  Discussing how fatal the disease is (essentially 100% in US domestic pigs) and the need to quarantine the farm to prevent the spread of disease to other farms will be important.  In this case, I would focus on the severity of the disease, the uncomfortable death these pigs and other infected pigs would go through, and focus on the most humane option of not allowing them to suffer.

    The farm will also be placed into a strict quarantine with no trucks, animals, people, etc. moving in and out.  The farm will be the central quarantine zone (also called the hot zone) as the outbreak is contained, studied, and hopefully eliminated.

  2. Please describe the different potential sources of ASF on this farm.

    The different potential sources of the ASF in this farm could be visitors of the farm accidentally (or intentionally) bringing ASF to the farm, the family may have visited another farm/country and brought the disease back with them, there is a possibility that the outbreak started at another farm and spread to this farm via wild boar or a fomite, etc.

  3. Please describe the different ways ASF can be prevented from entering into farms, regions, countries, etc.

    Biosecurity is the biggest prevention plan to keep ASF out of a farm, region, country, etc.  Biosecurity includes, but is not limited to, preventing animals/animal products from infected areas to enter into unaffected areas, not allowing humans who have traveled to an infected area to come to the unaffected areas without proper decontamination, showering in/out of facilities, boot washes, washing clothes, never feeding garbage or pig products to pigs, keeping equipment clean, quarantining new animals, etc.

    Helpful Links:


Day 3 Conclusion

I hope you enjoyed the pigs' case!  Don't forget to...

📚 Review material related to the pigs' case 

🤩 Get excited for upcoming cases

Dr. Haus's Unsolicited Life Advice: Read the hot zone, its a good book
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Saturday, November 11, 2023

Conclusion Caturday: Gaunt Gagging Goats (Case 4)

Picture of stuffed alpaca Professor Pocky and stuffed camel Douglas

Photo of TA Douglas (Left) and Professor Pocky (Right) taken by Dr. Haus
 

Click For Explanation of Case Flow

 

Click for Test Case Tuesday:  Gaunt Gagging Goats

 

Click for Thoughtful Thursday:  Gaunt Gagging Goats 

 

Quick Review


Diagnosis:

🪱PARASITIC INFECTION:  DICTYOCAULUS FILARIA🪱

 

Pathophysiological Point:

Dictyocaulus filaria (D. filaria) is a parasitic infection.  The D. filaria larvae are ingested by the goat and penetrate through the small intestines into the blood stream.  The larvae arrive at the lungs where they develop into adult lung worms.  As the larvae develop, they block bronchioles and lead to eosinophils, lymphocytes, and plasma cells entering the bronchioles causing an inflammatory state.  Some larvae/eggs fall into the alveoli leading to inflammation in the alveoli.  The eggs/larvae are coughed up, swallowed, pooped out, and the cycle continues.

 

 Questions, Answers, and Further Information:

 

Level 1 Questions, Answers, and Further Information:

  1. Explain what the lungs do and why they are important.

    The lungs are what allows the body to breathe.  Breathing is important because it brings oxygen into the body and gets rid of the carbon dioxide.

  2. Why do you think the goats are having trouble breathing?  (HINT:  Think about the effect a parasite in the lungs would have on breathing)

    The goats are having trouble breathing because the parasite is blocking the lungs and not letting the air flow smoothly into and out of the lungs.  The inflammation in the lungs is also making it harder to move air into and out of the lungs.

  3. Challenge question, why do you think the goats are losing weight?  (HINT:  There are multiple answers to this question.  Think about what parasites do to the body and how a parasite that makes it hard to breathe would affect the goats)

    There are two major answers to this question.  The first answer is that parasites steal the nutrients from a host so the goats are losing weight because the parasites are stealing the goats nutrients.  Also, since the goats need to work so hard to breathe they are not able to eat very much or for very long.  Next time you eat, try to breathe heavily and eat - it is hard to do!

    Helpful Links:

 

Level 2 Questions, Answers, and Further Information:

  1. Explain how inflammation in the alveoli affects the exchange of oxygen and carbon dioxide in the body.  Why does this lead to an increased respiratory rate in the goats?

    Inflammation leads to an increase of blood flow to an area of injury and increased leakiness of the blood vessels around an injury.  Due to this, the area begins to swell.  When is happens, the distance between the inside of the alveoli and the blood stream becomes greater.  This makes it harder for gases like oxygen and carbon dioxide to diffuse between the two spaces.  This inflammation also narrows the bronchi, bronchioles, etc. leading to less air getting to the alveoli.  

    The goats body will sense the lower oxygen concentrations and higher carbon dioxide concentrations in the bloodstream which will active homeostatic mechanisms to increase breathing rate to try to bring in more oxygen and release more carbon dioxide.

  2. How will this disease affect the compliance of the affected goats' lungs later in life?  (HINT:  Compliance is how well the lungs can expand to accommodate air.  Think about how the body heals injuries and how this might affect lung compliance)

    These goats will likely develop scar tissue in their lungs in locations where the parasites inflicted extensive damage.  Tissues that heal with scar tissue do not act as the "normal" tissue in that area will act.  In these areas of scar tissue, the body will not be able to exchange oxygen and carbon dioxide.  This will decrease the compliance of the lungs as they will not be able to stretch as much as normal lung tissue.

  3. Challenge question, explain the pulmonary mechanism that allows the parasite to spread between hosts in the fecal-oral route.  In other words, what mechanism allows the eggs produced by the adult lung worms to enter the gastrointestinal tract?

    The mucociliary apparatus (escalator) (MCA) is used by this parasite for its life cycle.  The MCA functions to capture foreign material from the lungs in mucus to be coughed up and swallowed.  This is exactly how the parasitic eggs will be able to be pooped back out into the environment to be picked up by a new host.  This will continue the spread of the parasite between animals.

    Helpful Links:

Level 3 Questions, Answers, and Further Information:

  1. Describe the treatment plan you would recommend for the goats and why you are recommending each part of your treatment plan.  Please answer this question as if you are speaking to a professional colleague.

    Given the clinical signs in the affected goats, they should be started on a deworming medication that targets the D. filaria.  This farm should begin to implement rotational grazing on their property and avoid putting young animals on pastures that have been inhabited for a long time by the older goats to decrease parasitic load.  The farm protocols and management should be reviewed to determine what other changes need to be made to decrease parasite load.  There is work being done to create a vaccination against D. filaria (the more you know).

  2. Describe your recommended treatment plan and why you are recommending each part of your treatment plan.  Please answer this question as if you are explaining it to a client/patient without a scientific background.

    Today we found lung parasites in your goats.  This means we need to treat the affected goats with a medication that kills the parasites.  Let's go over our farm protocols to see if there are other ways we can decrease the changes that your goats will be exposed to parasites.

  3. How does this disease affect these goat's V/Q ratio (ventilation/perfusion ratio)?

    This disease will affect the patient's ventilation and thus create a shunt.

    Helpful Links:



Day 3 Conclusion

I hope you enjoyed the goats' case!  Don't forget to...

📚 Review material related to the goats' case 

🤩 Get excited for upcoming cases

Dr. Haus's Unsolicited Life Advice: 1st thing you need to know to be a doctor: air goes in and out
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Saturday, November 4, 2023

Conclusion Caturday: Elaine Emits Exhaustion (Case 3)

Picture of stuffed alpaca Professor Pocky and stuffed camel Douglas

Photo of TA Douglas (Left) and Professor Pocky (Right) taken by Dr. Haus
 

Click For Explanation of Case Flow

 

Click for Test Case Tuesday:  Elaine Emits Exhaustion

 

Click for Thoughtful Thursday:  Elaine Emits Exhaustion 

 

Quick Review


Diagnosis:

🌌DILATED CARDIOMYOPATHY🌌

 

Pathophysiological Point:

Elaine is suffering from a disease where her body's heart is stretching and weakening.  As the heart stretches and weakens, her heart is having a harder time pumping blood throughout her body.

 

 Questions, Answers, and Further Information:

 

Level 1 Questions, Answers, and Further Information:

  1. Explain what the heart does and why it is important.

    The heart is the pump that moves blood around the body.  The heart is important in making sure nutrients like oxygen get to the cells and waste materials like carbon dioxide are moved away from the cells.  The heart allows the body to survive.

  2. Why do you think Elaine's echocardiogram showed that all four (4) of her heart chambers are dilated compared to normal?  (HINT:  Think about Elaine's diagnosis)

    Elaine was diagnosed with Dilated Cardiomyopathy which means she has a disease where her heart muscle is weakening and dilating.  This means the heart chambers are becoming larger as the muscle weakens.  This is noted in the echocardiogram and is due to her weakened heart.

  3. Challenge question, why do you think Elaine collapsed in her habitat?  (HINT:  Think about the heart's job and how Elaine's heart is a diseased heart that is not working properly)

    Elaine likely collapsed in her habitat because her heart is so weak it cannot pump enough blood to the body.  If not enough blood is pumping to the body that means there is not enough oxygen getting to her body.  Elaine's brain relies on the heart pumping oxygen to it and if the blood is not pumping well there is not enough oxygen getting to Elaine's brain.  When there is not enough oxygen getting to the brain, the brain does not work correctly and Elaine collapses.

    Helpful Links:

 

Level 2 Questions, Answers, and Further Information:

  1. Explain why Elaine has an atrial arrhythmia.  (HINT:  Heart conduction system)

    Elaine has an atrial arrhythmia due to the weakening and dilation of her heart chambers due to her diagnosis of dilated cardiomyopathy.  As the muscles around the right atrium weaken and stretch, the conduction system in that area is stretched as well.  In the right atrium, there is the SA node that starts the process of conducting a heart beat.  If the right atrium is dilated and weakened, the SA node is stretched and will not give off its electrical signals correctly leading to an atrial arrhythmia.

  2. How could Elaine’s viral infection from 10 years ago lead to heart disease (HINT:  How might a viral infection in the blood affect the heart?)

    Elaine's previous viral infection could lead to her current heart disease as the virus in the bloodstream may have infected her heart muscle and destroyed some of her heart muscle cells.  Over the years, her heart has been needing to work harder to pump blood and her heart cells may have been overworked and were slowly dying.  As the heart cells are slowly dying, her heart is slowly weakening and dilating.

  3. Challenge question, explain pathophysiologically why Elaine has jugular vein distention, edema in the neck, and ascites on physical exam.  (HINT:  Think about the heart's anatomy and how Elaine's heart chambers are NOT able to pump blood effectively)

    Elaine has jugular vein distension, edema in her neck, and ascites due to the inability of her heart to effectively pump blood through the heart.  Since her heart is weakened, Elaine's heart is not able to pump the blood from the right atrium to the right ventricle to the pulmonary artery with as much efficiency.  This causes the blood to start backing up into the cranial/superior vena cava and caudal/inferior vena cava.  As the blood pools in these locations, water starts to leak out of the blood vessels.  This causes the edema in the neck and the ascites in the abdomen.  The jugular vein distension is due to the blood pooling in the jugular vein as the heart is not pumping as much blood as quickly through the heart.

    Helpful Links:

Level 3 Questions, Answers, and Further Information:

  1. Describe the treatment plan you would recommend for Elaine and why you are recommending each part of your treatment plan.  Please answer this question as if you are speaking to a professional colleague.

    Elaine has been diagnosed with Dilated Cardiomyopathy (DCM) and there are countless treatments for heart diseases that depends on the patient's stage of disease, ability to administer treatments, and the goals for the patient's quality of life.  Some treatments for DCM might be changing the patient's diet if we believe there might be a dietary component, ACE inhibitors, Pimobendan, diuretics, anti-arrhythmic medications, etc.

    As a reminder, I am not an cardiologist and there are multiple correct answers to this question depending on the patient and the availability of care.  The important point to keep in mind is that with DCM we are prolonging the inevitable, there cannot cure the heart failure (unless we do a heart transplant).  We are keeping the patient's quality of life high through counteracting the negative side effects of DCM.

  2. Describe your recommended treatment plan and why you are recommending each part of your treatment plan.  Please answer this question as if you are explaining it to a client/patient without a scientific background.

    Today we have diagnosed Elaine with Dilated Cardiomyopathy.  This means Elaine's heart is slowly becoming weaker and weaker.  Elaine's weakening heart makes it hard for her to get all the oxygen she needs to her entire body.  At this time, we are going to start medications that will help Elaine pump blood through her body much more effectively.  We will keep Elaine on these medications as long as they are keeping her comfortable.  Unfortunately, there is not a cure for this condition so we will need to monitor Elaine's quality of life closely to determine the best plan for her care.

  3. Explain the pathophysiology of at least TWO (2) different etiologies of Dilated Cardiomyopathy.

    I am trusting you all to pick two etiologies of DCM and to explain the pathophysiology of them.  Be sure to view the helpful links below that will contain research articles diving into the pathophysiology of the potential causes of DCM.  it would also be interesting to look into the possible dietary links to DCM in dogs.

    Helpful Links:


Day 3 Conclusion

I hope you enjoyed Elaine's case!  Don't forget to...

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Dr. Haus's Unsolicited Life Advice: 2nd thing you need to know to be a doctor: Blood goes round and round

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Saturday, October 28, 2023

Conclusion Caturday: Florence Feels Feeble (Case 2)


Picture of stuffed alpaca Professor Pocky and stuffed camel Douglas
Photo of TA Douglas (Left) and Professor Pocky (Right) taken by Dr. Haus
 

Click For Explanation of Case Flow

 

Click for Test Case Tuesday:  Florence Feels Feeble

 

Click for Thoughtful Thursday:  Florence Feels Feeble 

 

Quick Review


Diagnosis:

🌌CHRONIC KIDNEY DISEASE (FAILURE)🌌

 

Pathophysiological Point:

Florence is suffering from a disease where her body's nephrons (kidney cells) are slowly dying.  This means her kidneys are slowly shutting down.

 

 Questions, Answers, and Further Information:

 

Level 1 Questions, Answers, and Further Information:

  1. Explain what the kidneys do and why they are important.

    The major kidney function are:  filtering the blood of waste products, regulating blood pressure, regulate production of red blood cells, breakdown of drugs, metabolism of hormones, synthesize vitamin D, manage electrolyte levels, and maintaining blood pH. 

    All the above functions of the kidney affect EVERY other organ system in the body.  The body cannot function very long if the kidneys are not able to complete all of their functions accurately.

  2. If Florence has dilute urine, what does she need to have access to AT ALL TIMES?  (HINT:  Dilute urine means Florence is peeing out more water than normal)

    Florence needs 24/7 access to WATER.  Her dilute urine means Florence is losing a lot of water in her urine and she will need to drink more water to replace all the water she is losing.  Florence is losing water because one of the kidneys jobs is to keep water in the body but if her kidneys are not working the water is lost in the urine instead of kept in the body.

  3. Challenge question, why does Florence have a low number of red blood cells in her body?  (HINT:  For this one you will need to do some information gathering on the kidneys' different jobs)

    Florence has a low number of red blood cells in her body because one of the kidneys' jobs is to tell the body to make more red blood cells.  If the kidneys are slowly failing, they cannot release a hormone called erythropoietin (EPO).  Without erythropoietin, the body does not know it needs to produce and release more red blood cells.

    Helpful Links:

 

Level 2 Questions, Answers, and Further Information:

  1. Explain pathophysiologically why Florence has pale gums on physical exam and is anemic on blood work.  Be sure to explain all the steps of the process that is NOT occurring in Florence due to her chronic kidney disease.

    Florence has pale gums due to her anemia. This anemia is caused by Florence's Chronic Kidney disease and the dying of her nephrons. The nephrons are responsible for releasing erythropoietin (EPO) into the bloodstream. After the kidneys release EPO, it travels to the bone marrow to stimulate erythropoiesis. This causes the bone marrow to produce and release red blood cells. With Chronic Kidney Disease, the kidneys can no longer produce enough EPO and the bone marrow is not receiving the stimulation to produce enough red blood cells for the body.

  2. Urea is a waste product that is normally urinated out of a patient's body via their kidneys and is an acid.  What acid-base status would you expect in Florence's bloodstream?

    Florence's acid-base status would be a metabolic acidosis (must have both terms to be correct).

  3. Challenge question, what TWO compensatory mechanisms are activated in Florence's body (there are two – assume the juxtaglomerular cells are still functional)?  (HINT:  Think about Florence's dilute urine)

    The two compensatory mechanisms which are activated in Florence are the Renin-Angiotensin-Aldosterone System (RAAS) and Anti-Diuretic Hormone (ADH).

    Helpful Links:

Level 3 Questions, Answers, and Further Information:

  1. Describe the treatment plan you would recommend for Florence and why you are recommending each part of your treatment plan.  Please answer this question as if you are speaking to a professional colleague.

    Florence has been diagnosed with Chronic Kidney Disease and there are countless treatments for Chronic Kidney Disease that depends on the patient's stage of disease, ability to administer treatments, and the goals for the patient's quality of life.  Some treatments for Chronic Kidney Disease are starting a patient on a renal diet to protect the kidneys, pH, electrolyte balance, etc. in the body, medications to decrease blood pressure (ACE inhibitors, angiotensin blockers, etc.), erythropoietin (EPO), subcutaneous fluids, phosphate binders, etc.

    As a reminder, I am not an internal medicine expert and there are multiple correct answers to this question depending on the patient and the availability of care.  The important point to keep in mind is that with Chronic Kidney Disease we are prolonging the inevitable, there cannot cure the kidney failure (unless we do a kidney transplant).  We are keeping the patient's quality of life high through counteracting the negative side effects of Chronic Kidney Disease.  See resources below for treatment recommendations based on IRIS staging.

  2.  Describe your recommended treatment plan and why you are recommending each part of your treatment plan.  Please answer this question as if you are explaining it to a client/patient without a scientific background.

    Today we have diagnosed Florence with Chronic Kidney Disease.  This means Florence's kidneys are slowly starting to shut down.  The kidneys are important for keeping Florence healthy and removing waste material from her body.  Florence is now losing a lot of water in her urine because she cannot keep it in her body due to her kidney disease.  We can help support Florence's kidneys to keep them as healthy as possible and to make her comfortable until her kidneys become too damaged.  This will include feeding her a diet that will protect her kidneys as well as providing her supplemental water.  Florence will also be placed on medications that will make her more comfortable and keep her feeling better.

  3.  Explain the pathophysiology of at least TWO (2) different etiologies of Chronic Kidney Disease.

    I am trusting you all to pick two etiologies of Chronic Kidney Disease and to explain the pathophysiology of them.  Be sure to view the helpful links below that will contain research articles diving into the pathophysiology of the potential causes of Chronic Kidney Disease.

    Helpful Links:

      

Day 3 Conclusion

I hope you enjoyed Florence's case!  Don't forget to...

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Dr. Haus's Unsolicited Life Advice: Stay Hydrated
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Saturday, October 21, 2023

Conclusion Caturday: Ruby Requests Rest (Case 1)

 

Picture of stuffed alpaca Professor Pocky and stuffed camel Douglas
Photo of TA Douglas (Left) and Professor Pocky (Right) taken by Dr. Haus
 

Click For Explanation of Case Flow

 

Click for Test Case Tuesday:  Ruby Requests Rest

 

Click for Thoughtful Thursday:  Ruby Requests Rest  

 

Quick Review


Diagnosis:

🌌IMMUNE-MEDIATED HEMOLYTIC ANEMIA🌌

 

Pathophysiological Point:

Ruby is suffering from a disease where her own body is producing antibodies AGAINST her own red blood cells.  This means her own body is destroying her red blood cells.

 

 Questions, Answers, and Further Information:

 

Level 1 Questions, Answers, and Further Information:

  1.  Explain why Ruby has a low number of red blood cells on her CBC.  (See Pathophysiological Point above for a hint)

    Ruby has a low number of red blood cells because her own body is destroying her red blood cells.  Even if her body is making more red blood cells they are being killed meaning she does not have enough red blood cells.

  2.  Why is having a low number of red blood cells in the body bad for a patient?

    Having a low number of red blood cells is bad for a patient because red blood cells bring oxygen to all the cells of the body.  The cells in the body need oxygen and if the body cannot bring oxygen to the cells the cells, and the patient, will die.

  3.  Challenge question, why is Ruby icteric on physical exam?  (Hint:  Icterus)

    Ruby is icteric on physical exam because her body is breaking down red blood cells at an increased rate.  Ruby's body/spleen (mentioning the spleen gets bonus points!) is removing the red blood cells from the body and when blood cells are broken down the body produces bilirubin.  If bilirubin is being created at an increased rate there is not enough time for the body to remove the bilirubin so the patient turns yellow, or icteric from excess bilirubin in the bloodstream (bilirubinemia).

    Helpful Links:

 

Level 2 Questions, Answers, and Further Information:

  1.  Given Ruby's disease process (see above), describe what is occurring at a cellular level to both the immune system cells and Ruby’s red blood cells.  Please be sure to address in your answer:
    • All blood cells involved in Ruby’s disease process (and how they are involved)
    • How the cellular changes are leading to her large and painful spleen

      Ruby’s disease process is activating her B-lymphocytes and leading to their differentiation into plasma cells.  These plasma cells are producing antibodies against Ruby’s own RBCs.  The antibodies are coating Ruby’s RBCs marking them for T-cell destruction.  Ruby’s T-helper cells are detecting the antibody covered RBCs and assisting the cytotoxic T-cells by activating them to destroy the RBCs.  The spleen recycles damaged and dead RBCs.  The large number of RBCs being recycled in the spleen is overworking the spleen leading to its large size and painfulness.

  2.  Explain pathophysiologically why Ruby is icteric on physical exam.

    Ruby is icteric on physical exam because of the excessive breakdown of red blood cells due to her diagnosis of Immune-Mediated Hemolytic Anemia.  In Ruby's case, her red blood cells are being marked for destruction by her own antibodies.  These antibody-coated red blood cells are detected in the spleen and the spleen breaks down the red blood cells.  One of the breakdown products of red blood cell breakdown is bilirubin.  This bilirubin is normally removed from the bloodstream by the liver to be excreted in the feces and urine.  For Ruby, she has such a large amount of red blood cell breakdown that her liver cannot keep up with the excretion of bilirubin, thus she has more bilirubin in the bloodstream than normal (hyperbilirubinemia) leading to her signs of icterus on physical exam (bonus points if you listed out the steps of bilirubin excretion).

  3.  Challenge question, explain why Ruby has both low red blood cells AND low reticulocytes.  (HINT:  Think about her disease process)

    IMPORTANT:  When RBC numbers are low, reticulocytes “should be” high.

    Reticulocytes are immature RBCs that should not be released from the bone marrow unless there is a large depletion of RBCs.  In Ruby’s case, the low reticulocytes are indicative of extremely severe disease.  Ruby should have large number of reticulocytes in her bloodstream to compensate for her low RBCs but in this case the antibodies are also destroying her reticulocytes.  Ruby’s bone marrow is completely depleted of RBCs AND reticulocytes meaning she is in an extremely severe disease state with total loss of oxygen carrying capacity.

    Helpful Links:

Level 3 Questions, Answers, and Further Information:

  1.   Describe the treatment plan you would recommend for Ruby and why you are recommending each part of your treatment plan.  Please answer this question as if you are speaking to a professional colleague.

    The answer to this question will be different depending on if you are approaching this question as a dog patient or a human patient.  I will answer this question in relation to a dog patient though the disease process and treatment plans are similar between dogs and humans.  As a reminder, I am not an internal medicine specialist.  😄

    Ruby has been diagnosed with immune-mediated hemolytic anemia (IMHA) and we need to immediately get her started on a blood transfusion (packed red blood cells or whole blood depending on what you have) due to her anemia.  Typically treatment starts with corticosteriods at an immune suppressing dose.  It is important to run further testing to determine underlying cause (tick-borne disease testing, cancer screening, etc.) because if we can find the underlying etiology we can create the best treatment plan.  Many clinicians will start doxycycline at this time to cover for an underlying infectious disease leading to the IMHA.  Patient's response to treatment will determine further interventions.

  2.  Describe your recommended treatment plan and why you are recommending each part of your treatment plan.  Please answer this question as if you are explaining it to a client/patient without a scientific background.

    Today we have diagnosed Ruby with a disease where her own body is attacking her blood.  Ruby's blood is important to bring nutrients to her entire body explaining why she is tired and not acting like herself.  We need to replace this blood Ruby has lost and treat her aggressively for her disease.  Due to Ruby's need for blood, we recommend Ruby to be hospitalized with 24/7 care until we can make her comfortable and stable.  The main treatment will be immune suppressing medication as it is Ruby's own immune system that is destroying her blood.  We need to stop her immune system so it will stop attacking her blood.

  3.  Explain the pathophysiology of at least TWO (2) different etiologies of Immune-Mediated Hemolytic Anemia.

    I am trusting you all to pick two etiologies of IMHA and to explain the pathophysiology of them.  Be sure to view the helpful links below that will contain research articles diving into the pathophysiology of the potential causes of IMHA.

    Helpful Links:

      

Day 3 Conclusion

I hope you enjoyed Ruby's case!  Don't forget to...

📚 Review material related to Ruby's case 

🤩 Get excited for upcoming cases



Dr. Haus's Unsolicited Life Advice: Practice explaining science to folks without a science background

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