Case log

1. University of Pennsylvania
Emergency Service and ICU
Externship Case Log
Lauren Ritchey
1003980r@student.gla.ac.uk

2. ICU
Patient 887022, ANAKEN, 10 year old, castrated
male Australian Shepherd
 Presenting Complaint: Persistent anorexia, vomiting, and lethargy
 Investigations Performed:
 Blood biochemistry: Significantly elevated liver values and total bilirubin
 CBC: Marked leukocytosis, neutrophilia, consistent with inflammatory response and/or infection. His platelets were mildly decreased.
 PT/PTT: wnl
 Abdomenocentesis and cytology: revealed exudative sample, with intracellular bacteria, and bile- consistent with a septic bile peritonitis
 Abdominal US: Serial US’s revealed worsening of previously diagnosed severe acute pancreatitis, with associated inflammation and free fluid
in his abdomen. Consistent with septic peritonitis. His biliary system was partially obstructed. His previously documented liver enlargement
and decreased gastrointestinal motility were subjectively unchanged from previous.
 Treatment:
 Exploratory laparotomy with peritoneal lavage, and JP drain placement.
 Patoprazole IV
 Ondansetron IV
 Maripotent IV
 Metronidazole IV
 Hetatarch and plasmalyte IV
 Lidocaine CRI
 Fentanyl CRI
 Metoclopramide IV
 Outcome:
 Treated for 3 days in ICU, owners decided to humanely euthanize.

3. ANAKEN
Partial bile duct obstruction Pancreatitis

4. ICU Patient 849512, DEXTER, 8 year old, castrated
male, DSH
 Presenting Complaint: 12 hour history of lethargy and inappetence. Previously diagnosed with IBD.
 Investigations Performed:
 COMPLETE BLOOD COUNT: The initial complete blood count revealed changes compatible with an acute onset of inflammation. When
repeated, these changes were still present and were more severe. He also became anemic during his stay.
 CHEMISTRY AND SERIAL FLEX PANELS: The initial chemistry panel showed elevation of his blood glucose, liver enzymes, and cholesterol as well as a
decrease of his calcium, consistent with acute pancreatitis. Serial panels were repeated during his stay. His liver enzymes normalized but his
blood glucose remained elevated. His phosphorus, magnesium, and albumin were transiently low but normalized.
 TOTAL T4: was decreased, which ruled out a diagnosis of hyperthyroidism. His low thyroid level was likely secondary to his underlying disease.
 URINALYSIS: Dexter's urine had a low concentration (1.018g/L) and contained glucose.
 URINE CULTURE: negative, ruling out a diagnosis of a urinary tract infection.
 CREATININE KINASE: elevated (3385U/L, normal 49-688), which can be caused by many etiologies including muscular damage, infectious and
noninfectious myopathies, necrosis, anorexia and many others. Toxoplasma titers were submitted to rule out a common cause of increased CK in
sick cats.
 TOXOPLASMA TITERS: negative
 BLOOD TYPE AND CROSSMATCH: Type A
 ABDOMINAL ULTRASOUND: revealed a severe pancreatitis with accumulation of free fluid in the abdomen. There was also thickening of the wall
of the common bile duct and thick bile in his gallbladder, which could have been caused by inflammation in the gallbladder and biliary tree.
Dexter's kidneys were mildly enlarged and had chronic changes. His liver appeared brighter than normal on ultrasound, which had already been
noted on his previous abdominal ultrasound. The appearance of his liver can be secondary to the administration of steroids (for his IBD) and/or
some degree of accumulation of fat in the liver.
 THORACIC RADIOGRAPHS: Thoracic radiographs were performed after Dexter developed increased respiratory efforts and rate. Changes
observed on radiographs were compatible with pulmonary edema (accumulation of fluid in the lungs). This could have been due to the high
volume of fluid needed to control his blood pressure and/or the presence of an underlying heart disease.
 ABDOMINOCENTESIS AND FLUID ANALYSIS: The fluid was analyzed three times during his stay and there was no evidence of organisms (bacteria)
or neoplasia. The accumulation of fluid in his abdomen was likely due to the inflammation around his pancreas leading to the leakage of fluid in
the abdomen.
 ESOPHAGOSTOMY TUBE PLACEMENT
 ECHOCARDIOGRAM: showed moderate tricuspid regurgitation as well as an enlargement of his atrium. The enlargement of his atrium may have
been secondary to the administration of fluids or was present prior to initiation of therapy for acute pancreatitis. The severity of the tricuspid
regurgitation was also significantly worse than on the previous echocardiogram performed 2 years ago. It remains unclear whether this represents
disease progression or exacerbation of regurgitation due to volume overload. No evidence of significant structural heart disease was identified
echocardiographically.

5. Dexter
 Treatment:
 IVF (stopped when pulmonary edema occurred)
 Pantoprazole, Cerenia, Ondansetron
 Previously rx chlorambucil, prednisolone, metronidazole
 E-Tube feedings
 Electrolyte supplementation (Ca, Mg)
 O2
 Ampicillin IV
 Fentanyl CRI
 Glargine insulin
 Outcome: Diagnosed with pancreatitis, diabetes mellitus, and
IBD. Stabilized in ICU, then went home with e-tube, and
continued on medical treatments at home.
2012
Present

6. ICU Patient 887392, ROYAL, 6 month
old, male entire English Bulldog
 Presenting Complaint: presented through emergency service in respiratory distress. Vomited and aspirated 2 days previous.
 Investigations Performed:
 RADIOGRAPHS: there was consolidation within the right middle, right cranial, and left cranial lung lobes that is most
consistent with potential aspiration pneumonia. His esophagus was segmentally dilated, most consistent with
aerophagia. Thoracic radiographs were repeated prior to discharge which showed large improvements in all lung
fields. Abdominal radiographs do not show any signs of mechanical obstruction causing his vomiting episodes. There is
no evidence of a static hiatal hernia, however this can occur as a dynamic process and may be displayed in X-rays.
 EMERGENCY BLOODWORK: During his respiratory crisis, his blood work revealed a markedly increased carbon dioxide
level, consistent with a complete upper airway obstruction and hypoventilation. The lactate was elevated indicating
a temporary decrease in oxygen reaching his tissues. After intubation and manual ventilation, an arterial blood gas
revealed a correct carbon dioxide level but a poor oxygen level despite the level of oxygen being provided to him.
This indicates a likely lower airway disease process contributing to his respiratory distress.
 EXTENDED BLOODWORK (CBC/Chem/Coagulation panel) His platelets and other coagulation values (PT and PTT)
were well within normal limits. CBC and Chemistry parameters were all within normal limits.
 URINE CULTURE: A urine culture performed following removal of his urinary catheter was negative for bacterial growth.
 ENDOTRACHEAL WASH: An endotracheal wash was performed which showed gram negative bacteria. Based off
these results, Royal was switched to an antibiotic susceptible to the bacterial grown.
 SURGICAL PROCEDURES: Royal underwent a soft palate resection, laryngeal saccule removal, castration, temporary
tracheostomy, and enlargement of his previously stenotic nares. His upper airway had significant swelling and
inflammation. Post operatively, he remained intubated via the tracheostomy tube and on the ventilator.
 Treatment and Outcome: Royal required emergency endotracheal intubation and ventilation to protect and manage an
open airway in order for him to breathe more comfortably. Upon intubation, his upper airway structures were identified as
causing a dynamic obstruction. He received gastroprotectants, anti-vomiting medications, antacids, and sedation. Royal
was transferred to the Intensive Care Unit for mechanical ventilation to maintain the tube in place and allow him to
oxygenate and ventilate normally. Upon transfer to the ICU, he remained on very low settings on the ventilator and
tolerated mechanical ventilation very well. He was brought to surgery and a temporary tracheostomy was placed to allow
for a good airway while his surgical sites were healing. He was gradually weaned off of the ventilator on 11/18/14 and his
tracheostomy tube was removed on 11/19/14. Royal was closely monitored and maintained on intravenous fluids and
medications for the remainder of his time in the ICU. He continued to improve throughout his stay and was switched to oral
medications prior to discharge. At the time of discharge he is eating and drinking normally with no episodes of
regurgitation. His breathing efforts and normal and he appears to be oxygenating appropriately.

7. Royal

8. ICU Patient 864200, BOGEY, 10 year old, castrated male
Yorkshire Terrier
 Presenting Complaint: reassessment of progressive coughing and respiratory distress. Bogey has a history of lower airway disease with collapse, tracheal collapse,
and pneumonia/tracheal infection. The tracheal collapse was treated with two tracheal stents in June 2013
 Investigations Performed:
 Initial stabilization in oxygen cage and given 0.2 mg/kg butorphanol IM (IM).
 COMPLETE BLOOD COUNT: Normal red blood cell and platelet counts. Total white blood cell count was normal except for mild monocytosis.
 THORACIC RADIOGRAPHS (11/19): No change in his tracheal stents and resolved area that was concerning for pneumonia at his last visit (caudal aspect of
left cranial lung lobe). There was an abnormal area of increased opacity in the left cranial lung lobe suggestive of local lung collapse, such as with a
bronchial obstruction by mucous, or pneumonia.
 TRACHEOSCOPY: A large amount of firm tissue was seen to be occluding 85-90% of Bogey's trachea. The abnormal tissue was growing in from the tracheal
wall into the stent, in the intra-thoracic portion of this trachea near the end of his first stent. The tissue appeared most consistent excess tissue production
following irritation & infection (granulation tissue) however a cancerous process within the trachea cannot be ruled out until biopsy results are available,
which are pending.
 TRACHEAL STENT PLACEMENT: Using fluoroscopic guidance and pre/post-operative tracheoscopy, a self expanding tracheal stent of the same size as his
original stent (Infiniti Medical 14/10 x 61) was placed within Bogey's trachea, nested within the previously placed stents re-open his airway. The stent was able
to completely compress the tissue along the wall of the trachea, restoring airway diameter, as confirmed via tracheoscopy.
 THORACIC RADIOGRAPHS (11/22): Repeat radiographs showed increased whiteness in the right cranial and middle lung lobes, consistent with aspiration
pneumonia (which is most likely due to aspiration of the bloody fluid from the biopsy/wash/re-stenting seen during his second tracheal scoping to confirm
placement and opening of the airway.
 ENDOTRACHEAL WASH: There were many inflammatory cells, but no bacteria were seen. Culture from this wash and tissue culture showed positive growth of
Staphylococcus pseudointermedius, which is susceptible to both the Baytril and Clindamycin he has been receiving
 Treatments:
 IVF
 intravenous antibiotics (Clindamycin & Baytril),
 Cough tablets as needed
 IV N-acetylcysteine
 IV terbutaline
 O2 supplementation
 Outcome:
 Recovered from stent placement in ICU for 3 days before being discharged and sent home on oral medication.

9. ICU Patient 866673, EDDIE, 11 year old, castrated male
Dachshund
 Presenting Complaints: Referral for elevated liver and kidney values and lethargy.
 Investigations Performed:
 INITIAL BLOOD WORK/LAB WORK:
 CBC - Eddie's initial complete blood count showed a mildly low platelet count with normal white blood cells and red blood cells.
 Chemistry - Eddie's initial chemistry profile revealed high kidney values (BUN, creatinine, phosphorous), norma electrolytes, and elevated
liver values (ALP, AST, Bilirubin).
 Urine culture - Eddie's urine culture here, and at his referring veterinarian, were negative. This makes urinary tract infection must less
likely.
 Urinalysis (from referring veterinarian) - Eddie's urine was analyzed right before coming to Penn. He had small amounts of glucose and
protein in his urine, as well as inappropriately dilute urine, indicating a problem with the tubules of his kidney. Recheck in-house urine
samples here revealed that the glucose in his urine resolved.
 Leptospirosis titers and PCR - Eddie's PCR and acute titers for leptospirosis, a disease that can cause liver and kidney damage, were
both negative. In order to confirm the absence of infection, convalescent titers were drawn on the day of his discharge. Convalescent
titers allow us to analyze the antibody response a few weeks after exposure, because it can take time for a true antibody response to be
mounted.
 Coagulation profile - Due to Eddie's nose bleed and evidence of vasculitis (inflamed blood vessels) and history of Cushing's disease
(which can predispose animals to throwing blood clots), a coagulation profile was run. His initial coagulation profile revealed evidence
of increased blood clot formation and breakdown (elevated D-dimers). A repeat coagulation profile was drawn later in his
hospitalization when Eddie developed acute respiratory distress (in case he threw a clot to his lungs); at this time, his coagulation profile
was normal.
 Abdominal US (serial)
 Echocardiography (serial)
 Lung fluid analysis
 Thoracic radiographs
 Diagnosis 1 (Confirmed) : Acute kidney injury, Chronic kidney disease, Hyperphosphatemia, Potential leptospirosis
Diagnosis 2 (Confirmed) : Degenerative valvular disease, acute heart failure (suspected chordae tendineae rupture), mechanical
ventilation, cough, exercise intolerance
Diagnosis 3 (Historical) : Cushing's disease, untreated
Diagnosis 4 (Confirmed) : Weight loss, progressive
Diagnosis 5 (Confirmed) : Elevated liver enzyme elevations, potentially doxycycline induced
Diagnosis 6 (Confirmed) : Urolithiasis (cystoliths, bilateral nephroliths)
Diagnosis 7 (Historical) : Intervertebral disc disease
 Treatments:
 Doxycycline
 Lanthanum (Phosphorus binder)
 Aluminum hydroxide (Phosphorus binder)
 Cerenia
 Denamarin (liver protectant)
 Omeprazole
 Mechanical ventilation, UCATH/UOP monitoring
 Esophagostomy tube placement and feedings

10. Eddie

11. ICU Patient 875310, GINGER, 12 year
old, spayed female Pomeranian
 Presenting complaint: Severe acute respiratory distress. Previously diagnosed with tracheal collapse, already received 2 stent
placement surgeries.
 Investigations:
 Stabilized in O2, given butorphanol IM.
 Thoracic radiographs: unchanged stent position, no evidence of pneumonia or other lung tissue changes. Mild cardiomegaly noted.
 Tracheoscopy: revealed almost completely obstructing collapse of the airway at the carina, and bronchi. Previously placed stents were still in
place, and no aberrant granulation tissue or masses present around the stents.
 Diagnoses:
 Diagnosis 1 (Confirmed) : Progressive cervical tracheal collapse - 16 x 60 tracheal stent 2/5/2014
 Diagnosis 2 (Confirmed) : Mainstem bronchial collapse
 Diagnosis 3 (Historical) : Grade 2/6 left apical systolic heart murmur
 Diagnosis 4 (Historical) : Perianal adenoma - completely excised 2/2014
 Diagnosis 5 (Historical) : Diffuse tracheal collapse - 14/21 x 71 and 14 x 30 tracheal stents placed Oct 2013
 Diagnosis 6 (Confirmed) : Bilateral medial patellar luxation
 Treatment:
 O2 supplementation
 IV bronchodilators
 Hydrocodone
 Outcome: A 3rd stent could not be considered due to the location of the airway collapse. Humanely euthanized.

12. Ginger

13. ICU Patient 887573, HENRY, 12 week
old, male entire Standard Poodle
 Presenting complaint: Referred for dialysis treatment after acute kidney injury.
 Investigations Performed:
 ECG (initially presented with sinus tachyarrhythmia- this resolved after single dose of lidocaine)
 Serial Abdominal US- revealed bilaterally enlarged kidneys, with evidence of inflammation.
 Serial blood biochemistry and complete blood counts- revealed severe azotemia, mild anemia, hypercalcemia
 Abdominal radiographs- revealed bilaterally enlarged kidneys, evidence of hepatic inflammation.
 Urine analysis, sedimentation and culture.
 Leptospirosis titers- positive.
 Urinary catheter placed, UOP monitored. Presented anuric initially, became polyuric post dialysis- this was closely monitored in order to try to
closely match IVF inputs with the body’s outputs.
 Treatments:
 Single Dialysis treatment
 Pantoprazole 0.7mg/kg IV q24
 Ondansetron 0.2 mg/kg IV q 8
 Doxycycline 5mg/kg PO q12 for 2 weeks (appropriate for later stage of Lepto)
 Metronidazole 10 mg/kg IV q 12
 Buprenorphine 0.01 mg/kg IV q 8-12 PRN
 Cerenia 1mg/kg IV q 24
 Free choice H2O
 Feed and note interest q 8
 Outcome:
 Received single dialysis treatment. Was then hospitalized for 5 days before he was discharged and sent home.
 Problem list:
 AKI – polyuric – leptospirosis confirmed
 Tachyarrhythmia – resolved
 Hypercalcemia – resolved
 Mild anemia – normal finding in a puppy vs. other causes

14. Henry

15. ICU Patient 859684, CREAMSICLE
12yo, castrated male, DSH
 Presentation: Presented in respiratory distress due to airway
obstruction. Was being managed for partial tracheal
obstruction due to recurrent tracheal carcinoma vs. less
likely granulation tissue associated with previous stenting.
Has received previous courses of chemotherapy and
radiotherapy. Abdominal mass discovered during most
recent investigations.
 Investigations Performed:
 Thoracic rads: tracheal soft tissue opacity; no evidence of
pulmonary metastatic disease; bronchointerstitial
pulmonary pattern unchanged from 4/2014
 Abdominal rads: large cranioventral abdominal mass
 Extended database: moderate respiratory acidosis (pH
7.246), moderate dehydration (PCV 43%, TS 8.5 g/dL, Na
157.2), mild hyperlactatemia (2.1 mmol/L); hypokalemia
(3.63 mmol/L)
 NIBP: 160 mmHg
 CBC/CHEM: elevated AST 51 U/L; elevated Mg++ 3.2
mg/dL
 TRACHEOSCOPY: previous tracheal stents intact; intra-
thoracic intra-luminal tracheal mass largely occluding
airway in previously stented portion
 Abdominal US: Left cranioventral cavitated fluid-filled mass
most likely arising from liver (vs. mesenteric) — ddx
neoplasia vs cyst; free peritoneal fluid ddx hemorrhage,
carcinomatosis, inflammation, infection; generalized hyper
echoic liver; chronic renal changes, splenomegaly, jejunal
corrugation w/ mild jejunal & ileal thickening
 POST-STENT EDB: resolution of respiratory acidosis (pH 7.347),
normalized K+
 CYTOLOGY (PENDING): tracheal wash, aspirates of
abdominal mass, aspirates of intra-cavitary fluid from
abdominal mass, peritoneal fluid
 CULTURE (PENDING): tracheal wash
 BIOPSY (PENDING): tracheal mass
 Flex 4 (Creat, BUN, Mg, P): results pending
 Crossmatch
 Coagulation panel: wnl
 Ascites cytology (In house): results pending
Treatments:
Placed on mechanical ventilator.
LRS @ 1.5ml/kg/hr +0.45% NaCl @1.5ml/kg/hr
Reglan 1mg/kg/day CRI
(1/4) Kmax 0.5meq/kg IV
Unasyn 22 mg/kg IV q8
Dex SP 0.1 mg/kg q24
Butorphanol 0.1-0.3 mg/kg/hr IV
Terbutaline 0.01 mg/kg IV q8
Midazolam 0.1-0.5 mg/kg/hr
Propofol 0.1-0.6 mg/kg/min
Cerenia 1mg/kg IV q24
Ondansetron 0.2 mg/kg IV q8
Glycopyrrolate 0.005mg/kg IV
Pantoprazole 1mg/kg IV q24
Norepinephrine 0.1meq/kg/min
Lasix 0.5mg/kg IV (one off dose given at 9am)
+/- RBC transfusion
Outcome:
Was maintained on the ventilator for 7 days in ICU, each time
weaning was attempted Creamsicle would respiratory obstruct.
The owner refused to consider humane euthanasia. Creamsicle
went into cardiac arrest on day 7 and after several rounds of CPR,
died.

16. Creamsicle

17. ES (Emergency Service) Patients 887116/114, HAZE and
MARLEY, 2 year old, spayed female DSHs
 Presentation: Possible lily ingestion.
 Investigations performed:
 EXTENDED DATA BASE: A blood screen used to check kidney values, acid/base and electrolytes was performed.
The initial results were within normal limits.
 PROGRESS: Haze was admitted and started on intravenous fluids. She was offered food and water and her
urination and vitals were monitored overnight. In the morning, urine was found in Haze's cage. She was
transferred to fluid wards for continued treatment and monitoring by the internal medicine service.
 TRANSFER TO INTERNAL MEDICINE; Haze was bright and alert for her physical exam. Her heart rate, respiratory
rate, temperature, and blood pressure were within normal limits for a stressed cat. A possible heart murmur was
heard on auscultation. However, it is difficult to be sure of this finding since she was breathing quite heavily at
the time. Her abdomen was soft and nonpainful and no other abnormalities were noted on physical exam.
Haze was maintained on IV fluids and blood and urine were collected.
 BLOOD WORK: No abnormalities were noted on a standard chemistry screen. Her CBC was normal except for
echinocytosis, which is most likely an artifact from sample handling. A limited chemistry screen was repeated
daily to monitor BUN, creatinine, sodium, and potassium. Her chemistry values were within normal limits every
day and she never showed more than a 0.1 increase in her creatinine.
 URINALYSIS: No abnormalities were detected in her urine. A urine dipstick was repeated daily and never
showed glucosuria or more than trace amounts of proteinuria which can be erroneous on the dipstick. Official
urinalysis showed no protein or glucose and very well concentrated urine.
 Treatments:
 IVF (Plasmalyte) at 4ml/kg/hr for 48 hours
 Monitoring BUN/CREAT/Electrolytes
 Outcome:
 Remained stable during hospitalization, no changes in BUN/CREAT/UA/electrolytes. Discharged and sent home.

18. ES patient 773870, ROXIE, 10yo,
spayed female, Boston Terrier
 Presentation: Painful at home. Pawing at face and eyes. Increased intraocular pressure OU.
Previously diagnosed with glaucoma- has been medically managed with carbonic
anhydrase inhibitors, beta blocker (Timolol), and PG analogues OU for the last year.
 Investigations performed:
 Tonometry: IOP 56 OS, 58 OD
 Fluorescein stain: revealed superficial corneal ulceration OD.
 Schirmer Tear Test: 15mm OS, 18 OD
 Transfer to Ophthalmology
 Ocular US
 Treatments:
 IV mannitol
 IV methadone
 Continue with ocular medical management until surgery.
 Outcome:
 Bilateral enucleation scheduled.

19. Roxie

20. ES patient 887883, CHARLIE, 2yo
castrated male Labrador Retriever
 Presentation: two day history of anorexia and discomfort. He vomited once two days ago, and
also passed a cloth object in his feces with some diarrhea. Today, he was taken to his primary
veterinarian where serial x-rays of his abdomen were taken which were suspicious for a foreign
body obstruction. Two weeks ago he had surgery for a gastrointestinal foreign body obstruction.
He received an enterotomy and gastrotomy, where two pacifiers and some cloth material were
removed
 Investigations performed:
 BLOODWORK: A mild inflammatory response was noted but the remainder of the values were
within normal limits.
 GASTROINTESINAL ULTRASOUND: Foreign material was observed in the early small intestines causing
a partial obstruction with inflammation of the areas nearby and dilation of a portion of the small
intestines.
 Treatments:
 SURGERY: An abdominal exploratory was performed in order to retrieve a foreign body from
Charlie's small intestine. The foreign material (a pacifier) was found in the early small intestine. It
was gently pushed backward into the stomach from where it was ultimately removed.
 Outcome:
 The procedure was completed without complication and Charlie's recovery from anesthesia was
uneventful.

21. CHARLIE

22. ES patient 786789, MARIUS, 13yo
castrated male Bichon Frise
 Presentation: 3 day history of diarrhea. Blood noted in stool. Previously treated for IMTP 3 years ago.
 Investigations performed:
 Minimum database PCV/TS: 59/6.7
 Complete blood count (CBC): This evaluates red blood cells, white blood cells and platelets. This test revealed a low
platelet count (52.6K) and no other abnormalities. The platelet count was low at 52,600 (normal is 177,000 - 398,000)
indicating a recurrence of his immune-mediated thrombocytopenia. Alternatively, it could represent consumption if
platelets are being used by the body in another area, like the gastrointestinal tract.
 Further diagnostics such as full bloodwork, an abdominal ultrasound and other tests are indicated to determine the
cause of Marius' low platelet count. At this time, the owner elected to treat the diarrhea symptomatically and
recheck a platelet count in 24 hours to see how the number is trending.
 Treatments:
 Metronidazole 10mg/kg PO BID 5 days.
 Outcome:
 Platelet count was rechecked 24 hours later, and dropped to 20,000. The owner rejected pursuing further
diagnostics and elected to take Marius home monitor his quality of life and bring him to his regular vet for humane
euthanasia when necessary.

23. ES patient 842084, CALLIE, 13yo
spayed female DSH
 Presentation: 12 hour history of being unable to stand up. She was last observed normal and able to
ambulate yesterday by her caretaker. Callie is a barn cat, who gets fed and cared for at least twice a
day. Over the last few months she has been losing some weight and condition, despite a normal
appetite.
 Investigations performed:
 NEUROLOGY CONSULT: On neurological examination some lumbosacral pain was noted. Mild right scapular muscle
atrophy was noted. She had torticollis to the right. She had decreased placing/proprioception in her legs but had
motor in all four. No menace response was detected bilaterally. Anatomic localization is suspected to be either
brainstem vs. C1-C5 +LS pain. Possible causes of these signs include multifocal causes such as lymphoma vs vascular
event vs other infectious/inflammatory causes.
 BLOODWORK: Her complete blood count showed an elevated platelet count, her serum chemistry panel showed
mildly elevated liver enzymes and her thyroid hormone level was markedly increased at 19.8.
 Treatment:
 We will start tapazole at 1/2 tablet twice a day along with the YD hyperthyroid diet.
 Outcome:
 It is difficult to determine if her neurologic signs are related to her hyperthyroidism. If she suffered a vascular
accident then her signs should improve over the next few days. If her signs are more due to multifocal disease like
lymphoma then she most likely will not improve or will get worse. Owner elected to take her home for the weekend,
monitoring her neurologic status and starting the medication for hyperthyroidism to see if she is easy to get
medications into. Her condition improved over the weekend and she was able to stand an walk on her own after
several days.

24. ES patient 887476, CLAUDE, 1 yo
castrated male DSH
 Presentation: acute onset of vomiting which coincided with him ingesting bandage material.
Claude had a history of dietary indiscretion.
 Investigations performed:
 INITIAL BLOODWORK: An emergency blood panel was performed, the results of which were
relatively unremarkable.
 ABDOMINAL ULTRASOUND EXAMINATIONS: Claude's initial (12/5/14) abdominal ultrasound
examination revealed gastric foreign material, with extension of the material through the pylorus
and into the duodenum. His next ultrasound (12/6/14) examination showed that the foreign
material had moved into the jejunum. Repeat ultrasound the following day (12/7/14) showed that
the foreign material was still in the jejunum, with evidence of regional inflammation (peritonitis).
 Treatments:
 SURGERY: Claude was placed under general anesthesia, and an abdominal exploratory surgery
was performed. Foreign material (cast padding) was identified in his jejunum and removed by
enterotomy (incision into the intestines). No additional abdominal pathology was appreciated.
 POST-OPERATIVE CARE: Claude recovered uneventfully from anesthesia and surgery. He was
hospitalized on intravenous fluid therapy and analgesia.
 Outcome:
 Post operatively Claude was eating well on his own, and had no episodes of vomiting. He was
discharged and sent home with oral analgesia.

25. ES patient 887941, CARLOS, 2yo
castrated male DSH
 Presentation: 24 hour history of straining to urinate. He had been urinating small, dime size
amounts in the litter box throughout the day. Recently his litter brand and type was changed
from a natural walnut based brand combined with a lightweight clay litter, to another brand.
 Investigations performed:
 URINE ANALYSIS: A urine sample was obtained via cystocentesis. An in house urinalysis revealed
that glucose, ketones, and bilirubin were all negative. His urine was well concentrated at >1.050.
Protein was found to be 300 mg/dL. Urine sediment revealed no significant abnormalities. There
were multiple fat droplets but very few cells. No bacteria were seen.
 URINE CULTURE: A culture was submitted to rule out infection. Results are pending. We will call you
when they become available.
 On PE bladder was large but soft and expressable.
 Treatments:
 SUBCUTANEOUS FLUIDS: 150mL of isotonic crystalloid fluids were administered under Carlos’s skin.
He may have a fluid pocket over the area for the next 24 hours.
 Buprenorphine 0.03mg/kg PO q8
 Prazosin 0.5mg PO BID
 Recommended management changes: water fountains, adding more litter boxes, switching
back to regular litter, increasing wet food/moisture in diet, monitoring urination, decreasing stress
levels.
 Outcome:
 Discharged and sent home on medical management, and monitoring.

26. ES patient 887952, DAKOTA, 5yo
spayed female Rottweiler
 Presentation: referred for for further evaluation of lytic toe mass (diagnosed at regular
veterinarian).
 Investigations performed:
 LYMPH NODE ASPIRATE: An aspirate of the lymph node draining her toe was obtained and
submitted for evaluation by the pathologist to look for evidence of metastatic disease (spread of
cancer). The results are pending, you will be notified of the results.
 SURGERY CONSULTATION: The surgeons felt that Dakota was a good candidate for toe
amputation.
 BLOOD WORK: Blood work was submitted to determine if Dakota is a good anesthetic
candidate.
 Referring vet Radiographs of all 4 limbs (from paws to elbow and knee). Revealing a lytic lesion
on 4th digit of her right front paw. Also bilateral hip dysplasia.
 Thoracic radiographs (3 view): wnl, no signs of metastatic disease.
 Treatment:
 Digit amputation, with biopsy of mass.
 There are several possibilities for the swelling of Dakota's toe. The most likely cause is a tumor with
less likely causes being an infectious process or benign growth. Common malignant tumors of the
digits include squamous cell carcinoma, malignant melanoma, and other various sarcomas
including osteosarcoma. The most likely cause in Dakota was though to be squamous cell
carcinoma given her breed and coloring as well as the bone lysis.
 Outcome:
 Transferred to the surgery department for digit amputation and further diagnostics. Will continue
on to oncology pending biopsy results.

27. DAKOTA

28. ES patient 825516, ABIGAIL, 11yo
spayed female English Bulldog
 Presentation: 3 day history of diarrhea. She also vomited up her bland meal last night. She was seen and treated by her
primary veterinarian about 2 weeks ago for diarrhea. Over the last 6 months Abigail has been losing weight (estimated 10
lb), having intermittent diarrhea every 3-4 weeks that is generally self-limiting and occasional vomiting. She has also had
increased respiratory noise progressively over time. Abby is exercise intolerant which has been ongoing due to her arthritis
and historic cruciate tears bilaterally.
 Investigations performed:
 Emergency blood work: NOVA: This is an emergency blood screen that was used to assess Abigail's electrolytes, glucose and renal
values. Findings were supportive of a mild dehydration.
 Abby was transferred to the Internal Medicine Service on 12/7/2014:
 Complete blood count (CBC): normal red cell, white cell and platelet counts
 Chemistry panel: decreased albumin and low globulins *low blood proteins), mildly elevated ALP.
 Normal kidney values and electrolytes and blood glucose.
 Thoracic radiographs: no evidence of metastasis or abnormalities
 Abdominal ultrasound: GIT thickening diffusely. Recommend intestinal biopsies.
 Urinalysis: A urine sample was obtained by ultrasound-guided cystocentesis. NAD.
 Urine culture: Results are pending. We will contact you when results are available.
 Fecal float: this is a test for intestinal parasites, NAD.
 Fecal screen: this is a test for campylobacter and salmonella, NAD.
 GI panel: B12 and TLI pending
 Treatments:
 Metronidazole
 IVF
 Cerenia
 Panacur dewormer
 Food trial.
 Outcome: Discharged, sent home on medical management. Recommended intestinal biopsies- owner will consider. Also
recommend airway exam if owner decides to pursue biopsies.

29. ES patient 887956, SPARTACUS, 3yo
castrated male Pit bull mix Presentation: Referred after being recently treated at his primary vet for suspected kidney injury and dehydration.
 Investigations performed.
 ***EMERGENCY SERVICE DIAGNOSTICS, TREATMENTS, AND PROGRESS***
 BLOOD PRESSURE: Spartacus's blood pressure was increased at 210 mmHg. This was likely due to pain and kidney disease. His blood pressure normalized later in his hospitalization.
 EMERGENCY BLOOD PANEL: Spartacus had elevated kidney values and some electrolyte abnormalities. His kidney values were improved from last check prior to referral. [Elevated
kidney values (BUN 50, Creatinine 2.3) elevated sodium (162), decreased potassium (3.7), and mildly elevated chloride (124).]
 ELECTROCARDIOGRAM: An eletrical tracing of his heart was performed due to the low heart rate.
 Spartacus had sinus bradycardia (atropine responsive), with a heart rate of 64 beats per minute. This was likely secondary to his illness and improved as he improved.
 ABDOMINAL ULTRASOUND: Abdominal ultrasound revealed severely inflamed and enlarged kidneys consistent with acute kidney injury
 ***MEDICINE DIAGNOSTICS, TREATMENTS, AND PROGRESS***
 COMPLETE BLOOD COUNT (12/7): He has white blood cell changes consistent with infection or inflammation. [Elevated white blood cell count (23,000) with a left shift (19,000
segmented neutrophils), increased monocytes (2,300) and reactive lymphocytes.]
 BLOOD CHEMISTRY (12/7): Spartacus's kidney values remained elevated, and his electrolyrtes improved somewhat overnight. Spartacus also had an elevation in one of his liver
enzymes, ALP, which can occur with leptospirosis. [Elevated renal values (BUN 39, Creatinine 2.7), increased sodium an chloride (159 and 122 respectively), decreased potassium
(3.7), and increased alkaline phosphatase (517).]
 URINALYSIS: He was not concentrating his urine with a USG of 1.007 (hyposthenuric) and had some blood present in his urine (4+). URINE CULTURE: Negative
 SERUM LEPTOSPIROSIS TITER: Spartacus was tested for an immune response to leptospirosis. He had a very elevated titer, consistent with recent infection
 SERIAL MONITORING OF KIDNEY VALUES: Over the few days in the hospital, Spartacus's kidney values initially returned to the normal range. They increased slightly as fluids were
weaned. At the time of discharge, completely off fluids, his valuse were slightly above the normal range (indicating at least 75% loss of kidney function) with increased phorphorus
and potassium (electrolytes excreted by the kidney). Spartacus's kidneys may recover further over the next few weeks, or he may have residual chronic kidney injury that will require
management.
 Treatments:
 During initial hospitalization in ES:
 IVF
 Methadone IV
 Ampicillin
 Enrofloxacin
 Transferred to Medicine department for further hospitalization, diagnostics and treatment.
 Outcome:
 Was hospitalized for several days on supportive care before Leptospirosis titers came back positive. He was started on Doxycycline treatment and continued on IVF, pain management,
and gastric protectants. He became much brighter, began eating well, and was sent home on oral treatment.

30. ES patient 887954, ZAR, 8yo intact
male German Shepherd
 Presentation: acutely unable to bear weight on right hind leg. Zar lives outside and is a guard
dog in a junk yard. He likes to jump on an off of cars, and this is likely how he injured himself.
 Investigations performed:
 SEDATED PELVIC RADIOGRAPHS: Zar was sedated for radiographs of his pelvis. These radiographs
showed a right craniodorsal coxofemoral (hip) luxation. (Official report pending)
 NSAID PANEL: This bloodwork was performed to assess Zar's liver and kidney values. There was a
mild increase in AST likely secondary to muscle damage sustained during his trauma.
 URINALYSIS: During his anesthesia, Zar was dripping red-tinged urine from his prepuce. He was
catheterized and a urine sample was obtained. There was a small amount of protein and
occasional red blood cells on sediment exam.
 Treatments:
 CLOSED HIP REDUCTION AND EHMER SLING PLACEMENT: Zar was placed under light anesthesia.
Using manual force the head of the femur was replaced into the acetabulum. A sling was placed
to keep Zar's right leg in a non-weight bearing position with the head of the femur in the
acetabulum of the pelvis. Radiographs were taken post-reduction and post-sling placement to
confirm that there was no re-luxation.
 Outcome:
 Zar was sent home to recover indoors with strict rest. He was placed on tramadol, rimadyl, and
acepromazine (as needed, if becomes anxious indoors). Recheck appointment in 1 week for
repeat hip radiographs to check sling placement and healing.

31. Zar

32. ES patient 887967, BIGZ, 2 yo,
castrated male Boxer
 Presentation: 2-3 day history of coughing. Three days previous he had and episode
of vomiting, which had since resolved. Shortly after the cough resolved Bigz
developed a cough. The cough is exasperated by exercise.
 Investigations performed:
 THORACIC AND NECK RADIOGRAPHS: Normal cardiac structures. No evidence of pneumonia
was observed on the radiographs.
 Treatment:
 Bigz's radiographs showed no evidence of pneumonia. Given the sensitivity on tracheal
palpation and his history, we are treating him for tracheitis (inflammation of the trachea).
Possible causes include infections such as kennel cough, allergies or traumatic irritation such
as from a pulling on a leash excessively. We are treating him with an antibiotic for a potential
infection, such as Bordetella.
 Doxycycline 150mg PO BID 10 days.
 Outcome:
 Sent home on medication for tracheitis. Recovered well per owner on follow up call. No
further complications.

33. ES patient 768537, GENEVIEVE, 13yo
spayed female Yorkshire Terrier
 Presentation: yelped and started limping on her right front paw today during
her walk. She was initially non-weight bearing on her right front limb, but she
seems to have improved since the incident. Genevieve has a history of shifting
intermittent lameness, a cause for which has never been identified. Genevieve
has been previously seen here at the hospital for a protein losing nephropathy,
for which she is being medically treated.
 Investigations performed:
 There were no abnormalities on orthopedic examination
 Lameness may be caused by a variety disease processes such as inflammation,
infection, neoplasia or trauma involving bones, muscles, nerves, joints, tendons, or
ligaments. Radiographs of the affected limb may help determine a cause of the
observed lameness. In some cases, advanced imaging (MRI/CT) may be necessary to
appropriately determine a cause of lameness.
 Diagnostic investigations rejected by owner.
 Treatments:
 Tramadol 12.5mg PO BID
 Outcome:
 Sent home on pain management. Limping resolved on medication per owner when I
called for update.

34. Rotation Reflection
My rotation at the University of Pennsylvania consisted of 2 weeks in the ICU and 2 weeks in
the Emergency Service. In the ICU the students are expected to write daily SOAPs on all of
the patients, participate in daily rounds, assist the nurses with treatments, and write patient
discharge letters. The day starts at 6:50am, as ‘pick ups’ or transferred patients from other
departments are moved into ICU at 7am and students are expected to assist with this and
any diagnostic procedures necessary. We would usually finish by 7pm. During my time in ICU
we were quite busy, but still managed to get daily rounds with the senior clinicians. Some of
the round topics included: blood gas analysis, ventilator basics, fluid therapy, septic
peritonitis/SARS/ARDS/DIC/Sepsis, brachycephalic airway syndrome, CPR, ECG interpretation,
acute kidney injuries. We also got to participate in a cadaver lab where we were able to
practice cut downs, thoracostomy tube placement, tracheostomies, pericardiocentesis,
thoracocentesis. I found the rounds and cadaver lab to be invaluable. During my time in ICU
we had several ventilated patients, with very complex cases. I had not experienced this level
of complexity of care before and it was a really amazing learning experience.
During the Emergency Service rotation students get to experience a high volume case load.
You are expected to do a full physical exam on your patients, obtain a full history from the
client, and then formulate your own differential list, diagnostic and treatment plans and
present them to the attending clinician. Their expectations are high, so it can be a little nerve
wracking at first, but it really pushes you to think things through and be able to explain why
you are making all your decisions. You are pushed to make decisions and justify them- the
way you will need to in a few months when you qualify. You also receive rounds twice a
week during the ES rotations. The ES rounds topics included- emergency triage, ophthalmic
emergencies, foreign body obstruction case evaluation, and day 1 fears (we talked about
cases we are scared/nervous to see next year when we get out into practice on our own).
Overall, the ICU/ES rotation at Upenn was an amazing experience and I would highly
recommend it.