March 2006 Issue

Featured case study:
Eight-year-old neutered male yellow Labrador retriever, Tennyson
by Dr. Nolie Parnell, DVM, DACVIM, clinical assistant professor, small animal medicine, Purdue University School of Veterinary Medicine, West Lafayette, IN

Physical Exam

Tennyson weighed 78 pounds, an approximate loss of slightly more than 10 pounds over the past year. He was severely dehydrated.

• Temperature—101.1°F
• Pulse—128
• Respiration—24
• Mucous Membranes—tacky and pink, CRT <2 seconds
• Oral Exam—halitosis noted (uremic breath)

Differential diagnoses

With the history of renal disease and the clinical presentation, chronic renal disease is the primary differential. However, specific disease differentials include leptospirosis, glomerulonephritis and amyloidosis.

Plan

To thoroughly characterize the renal system, a complete blood count, clinical chemistry profile and urinalysis were requested. In addition, diagnostic imaging, including radiographs, an ultrasonographic evaluation and a urine culture, were requested.

Erythron—There is a mild, normocytic, normochromic anemia. The lack of polychromasia suggests nonregenerative anemia. Mechanism of the anemia is most likely associated with the renal disease and decreased erythropoietin production.

Leukon—The primary leukocyte abnormalities include lymphopenia and eosinopenia, which most likely are associated with an endogenous glucocorticoid influence. Prednisone therapy was stopped earlier and there is an unlikely residual effect. Thrombon—Platelet numbers are only slightly and insignificantly decreased. Figure 1—Peripheral blood film, Wright’s stain: Note the nonspecific abnormality in erythrocyte morphology (poikilocytosis) and the mild decrease in red blood cell density, supporting the laboratory findings of mild anemia.

Kidney panel—The marked increase in urea, creatinine and phosphorus indicate a marked decrease in glomerular filtration. This, in combination with the finding of an isosthenuric (fixed/nonconcentrated) urine specific gravity, indicates renal failure. The 2+ proteinuria in an isosthenuric urine suggests significant protein loss. However, hypoalbuminemia that is commonly seen with severe protein-losing nephropathy is not observed. Accurate quantitation of the potential protein loss should be considered with the measurement of the urine protein:creatinine (UPC) ratio. The UPC ratio for Tennyson was 0.6; values greater than 0.5 in an azotemic dog are considered to be abnormal and, depending on the degree of proteinuria, monitoring, further investigation and potential therapy should be considered.

Calcium—There is a minimal hypercalcemia noted. Although hypocalcemia is more common in dogs with chronic renal failure, cases of advanced severe renal secondary hyperparathyroidism with marked hyperplasia of the parathyroid glands may result in hypercalcemia.

Acid-base—Although the sodium, potassium, chloride and TCO₂ (bicarbonate) are all within reference range intervals, the TCO₂ is on the extreme low end of the reference range and the anion-gap is mildly increased, indicating that there is an increase in the amount of unmeasured anions. In this case, the increase is most likely associated with retained organic acids, including phosphates and sulfates that are not being filtered through the kidney. Changes are consistent with a titrational metabolic acidosis.

Diagnostic imaging—Ultrasound evaluation supported other laboratory findings. Renal pelvises were bilaterally dilated and there was little to no medullary component within the kidneys. Both kidneys were small and there was a cyst noted on the left kidney.

Final diagnosis

The finding of renal azotemia, mild nonregenerative anemia and the diagnostic imaging finding of small kidneys with little or no medullary component all support chronic end-stage renal failure. Clinical and laboratory findings support uremia.

Therapeutic plan

• Normosol-R®—diuresing fluid rate to help decrease urea and creatinine concentrations; monitor closely for fluid overload
• Famotidine (H2 blocker)—decrease gastric acid production in an attempt to prevent or treat any gastritis or bleeding that may be present
• Ammonium hydroxide—phosphorus binder in an attempt to limit the secondary hyperparathyroidism
• Continue Hill’s K/D diet—low protein and phosphorus to help decrease workload on kidney, low sodium to help prevent hypertension, fortified in B complex vitamins often lost in polyuric animals, high-fiber content to increase gastrointestinal excretion of nitrogenous wastes
• Metaclopramide—anti-emetic (change to ondansetron if vomiting is not controlled)
• Unasyn®—semisynthetic antibiotic ampicillin sodium for potential pyelonephritis (bilaterally dilated renal pelvises)

Day 3

Clinical findings—Tennyson gained weight, most likely primarily associated with the restoration of normal hydration status. He appeared to be in greater discomfort and was also panting.

Laboratory data

Kidney panel—The mild decreases in urea, creatinine and phosphorus indicate some response to fluid therapy, however, there is still a pronounced decreased glomerular filtration rate.

Acid-base—The TCO₂ has increased. This has resulted in a return to within reference-range limits for the anion gap which suggests correction of the metabolic titrational acidosis.

Pancreas—The marked increase in amylase and lipase support the presence of an active pancreatitis. Cause is not immediately obvious, however, two potential causes could be considered. The pancreatitis may be associated with an ischemic event resulting from the severe dehydration seen on presentation. Additionally, pancreatitis associated with the renal secondary hyperparathyroidism with enhanced cellular (including pancreatic acinar cellular) uptake of calcium and subsequent cell injury or death should be considered.

Clinical case outcome
Due to the extremely poor prognosis for Tennyson, the owners elected humane euthanasia.

The recommendations contained in Diagnostic Edge educational materials are intended to provide general guidance only. As with any diagnosis or treatment, you should use clinical discretion with each patient based on a complete evaluation of the patient, including history, physical presentation and complete laboratory data. With respect to any drug therapy or monitoring program, you should refer to product inserts for a complete description of dosages, indications, interactions and cautions.

We want to hear from you. Let us know what you think about this case and tell us about any other case topics that you would like to see. E-mail us at diagnosticedge@idexx.com.

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Announcing IDEXX VetVault®—Focus on caring for your patients while we care for the security of your client and patient data

The IDEXX VetVault® service works over the Internet, leveraging state-of-the-art data-storage capabilities that render traditional tape backup and off-site data storage obsolete. Key benefits include:

Simplicity
The IDEXX VetVault service simplifies your job by reducing the purchase, cataloging and storage of tapes, eliminating the aggravation of scheduling staff after-hours to complete backups, as well as the worry of having a valid backup of your business-critical information.

Security
Data transmissions to and from the vault are encrypted using the strongest commercially available algorithm. While in the vault, the data is protected by an advanced data center infrastructure and resides in a proprietary format that is virtually inaccessible to unauthorized users.

Business continuity
This service ensures data is kept off-site in a secured facility so that if your on-site data is ever damaged or lost, it can easily be restored to your clinic via the Internet or by mailing a data tape overnight.

IDEXX VetVault is a reliable, secure, automated backup and recovery service for veterinary clinics. It was designed to bring peace of mind to your clinic by securing and protecting your data so it’s available when you need it.

For more information or to request a quote, contact your IDEXX Computer Systems sales representative at 1-800-283-8386 or e-mail diagnosticedge@idexx.com.

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Are you getting the most out of your LabREXX® software?

Did you know that you can automatically create invoice items for tests that you have not set up in the LabLink? During the simple initial configuration of LabREXX, choose a classification and markup percentage to use when creating these new invoice items. When you choose a test you have not previously used, Cornerstone® will create the necessary invoice item with a price calculated from your practice’s cost multiplied by the markup percentage. These charges will be transferred to the Patient Visit List, ensuring that your practice is capturing all available diagnostic revenue.

You can also use LabREXX to verify that the tests you have selected are applicable to your patient. Once you have chosen all of the diagnostics you want to run, LabREXX automatically verifies that they are applicable to the particular species and checks to see that all required information has been provided. When the LabREXX requisition form window appears, the “Finished” button is disabled and a red exclamation mark indicates issues. Move from form to form by clicking “Next” or “Previous.” You can maximize the window by double-clicking the title bar. After all issues have been resolved, the “Finished” button is enabled. Click the button to continue and print your requisition forms.

If you have any questions about Cornerstone® 6.2 software, or LabREXX® call us at 1-800-283-8386 or e-mail diagnosticedge@idexx.com.

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Inhibit Sticker Shock When Presenting Estimates
by Wendy S. Meyers

Using positive body language and convincing phrases can help you confidently present estimates. Because doctors recommend surgery or procedures based on medical need, call the estimate a “treatment plan.” The word “estimate” focuses on money, not on the care the patient needs. Also have staff—not doctors—present estimates.

You can improve compliance for patients with an effective reminder system. Send reminders weekly rather than monthly to keep a steady flow of clients booking appointments, even out cash flow and reduce stress for staff and doctors. Try a three-tiered approach:

When discussing treatment and finances, don’t stand behind the exam table and talk across it to the client. This face-to-face posture might be perceived as confrontational. Instead, stand at the end of the exam table, forming an “L” shape between you and the client. Even better, stand on the same side of the exam table, shoulder-to-shoulder with the client. This body language is collaborative rather than confrontational. The technician would then say, "I want to go over the treatment plan the doctor recommends for your pet."

Pictures help clients better understand procedures, and an educated client is more likely to comply with the doctor's recommendation.

Explain each item, pointing to the left column that lists medical services. Don’t point to the right column—it has prices. Consider creating a three-ring binder with labeled pictures for common procedures, such as dental cleanings, spays and neuters. Match the order of photos to your estimate format so you can flip picture pages as you describe each medical service. For example, show a photo of a technician running in-house bloodwork while explaining preanesthetic testing. Show a picture of a pulse oximeter and ECG when describing monitoring. Pictures help clients better understand procedures, and an educated client is more likely to comply with the doctor’s recommendation.

When finishing presenting the treatment plan, the technician asks, "Is this the level of care you’d like for your pet?" When the client responds yes, say, "To schedule/proceed with treatment, I need your signature on the treatment plan." If an emergency, say, "To begin emergency treatment of your pet, I need your signature and a deposit of $(the amount your practice requires)." Many practices require a 50% deposit for emergencies.

With training, you'll become a confident communicator and get more patients the care they need.

If the client cannot afford that level of care, the technician says, "Let me get the doctor so she can recommend Plan B/options for a treatment plan that fits your budget." Oftentimes, the client will find a way to pay for the needed care. If not, the doctor can revise the treatment plan based on medical need rather than cost. To practice this skill, print an estimate from your veterinary software. Role-play conversations with staff and ask them to suggest improvements in your body language and phrases. With training, you’ll become a confident communicator and get more patients the care they need.

Wendy S. Myers owns Communication Solutions for Veterinarians in Denver, Colorado, and provides consulting services on client service, marketing and hospital management. She is the author of two books and four videos. You can reach her at 1-720-344-2347 or visit www.mycommunicationsolutions.com.

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Education and Events

We offer a variety of training events about emerging trends and best practices in veterinary diagnostics in a forum designed to involve, educate and motivate you and your staff. Here are some of the upcoming educational events. See a full listing.

Webinar

• Uncover Early Renal Disease: Integrate UPC Ratios Into Your Practice
  Fred Metzger, DVM, DABVP, and Michelle Kahn, MS, DVM

Teleconferences

• Diagnosing Canine Pancreatitis
  Jörg M. Steiner, med.vet., Dr.med.vet., PhD, DACVIM, DECVIM-CA

Seminars

• Tick-Borne Diseases in Dogs
  Rick Alleman, DVM, PhD, DABVP, DACVP
• Canine Lyme Disease for the Canine Practitioner
  Steven Levy, VMD

Visit the education and events calendar, click the date to view the details, fill out and submit the form to register.

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Announcing CE credit for the Diagnostic Edge Interactive Challenges—Beginning in the April 2006 Issue

Can you identify this cell type and material?

Can you identify the cell type (A) and the material (B) indicated with arrows? (Wright’s-stained fine-needle aspirate from the liver of a dog)

Send your answer in an e-mail to diagnosticedge@idexx.com. Please include your name, practice name, address and telephone number.

The first 10 respondents to correctly identify the cells and structure will appear in the next issue of the Diagnostic Edge.

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