Clinical Cases Focus on Respiratory and Cardiology

1. Clinical CasesFocus on Respiratory and Cardiology Dusty W. Nagy, DVM, MS, PhD DACVIM University of Missouri Food Animal Medicine, Surgery,and Production Medicine

2. Case Workup • Signalment • History • Physical Examination • Problem List • Differential Diagnoses • Prioritized list • Avoid zebras • particularly the pink and chartreuse ones

3. Case Workup • Initial diagnostic and treatment plan • Prioritize tests • Utility – rule in or rule out differentials • Need to know info for treatment • Analyze test results • Changes to the plan • Outcome • Reflection

4. Case 1

5. Chief complaint: weak, appears drunk • Signalment: 9-year-old black crossbred cow • History: Cow was seen off by herself this morning. They assumed that she was trying to calve. When no calf was noted by noon they went to check on her. She rushed the owner and rammed several farm vehicles while taking her to the barn. • Environment: August in central Missouri. Cow is one of 32 in a cow calf herd. They are housed on 80 acres of mostly fescue grass subdivided into 3 pastures. University of Missouri #

6. Physical Examination • Appearance Body condition score 5/9 Normal abdominal contour • Behavior Belligerent Aggressive • Gait and posture Weak Stands base wide on all 4 Sways while walking • Urine analysis yellow/orange color No analysis done • TPR Temperature – 104.2 ºF Pulse – 92 bpm Respiratory rate – 52 bpm

7. Physical Examination – left side • Rumen Decreased content Poor stratification • Pings No pings • Lymph Nodes prefemoral – normal prescapular - normal • Lung auscultation normal breath sounds • Heart auscultation Rhythm – regular, fast Intensity – normal Sounds – no murmurs or arrhythmias • Jugular vein Normal • Cervical skin tent < 2 seconds

8. Physical Examination – right side • Pings No pings • Seccussion No fluid sloshing • Ballotment normal • Lymph nodes Prefemoral – normal Prescapular - normal • Lung auscultation Normal breath sounds • Heart auscultation Rhythm – regular, fast Intensity – normal Sounds – no murmurs or arrhythmias • Jugular vein Normal • Cervical skin tent < 2 seconds

9. Physical Examination • Abdominal pain None present • Skin normal • Extremities normal • Musculoskeletal normal • Head Ocular discharge - none Eye examination - normal Nasal discharge - none Mucous membrane color - yellow Teeth - normal

10. Physical Examination • Mammary gland Inflammation none present Strip cup no abnormalities California mastitis test • Rectal palpation Third trimester fetus • Feces Dry/firm Large amount in rectum Problem list

12. Problem list • Tachycardia • Tachypnea • Fever • Jaundice • Abnormal behavior, posture and gait • Abnormal fecal consistency Prioritized list of differentials

13. Differential diagnosis • Tachycardia/Tachypnea • Cardiac disease • Respiratory disease • Disease that affects oxygen carrying capacity • Pain • Stress • Jaundice • Liver failure • Hemolysis • Intravascular • Extravascular

14. Differential diagnosis • Fever • Infection • Inflammation • Abnormal posture and gait • Neurologic disease • Musculoskeletal disease • Disease that affects oxygen carrying capacity • Abnormal fecal consistency • Gastrointestinal disease • Dehydration Initial diagnostic and treatment plan

15. Diagnostic plan Treatment plan • CBC • PCV/TP • Arterial blood gas • Serum biochemistry • Urinalysis • Complement fixation/PCR • Antibiotics • Oxytetracycline 9mg/lb SQ EOD • Low stress environment

17. Interpretation • CBC Anemia – loss Anisocytosis Polychromasia Erythrocyte basophilic stippling Peripherally located erythrocyte parasites

18. Update – after 2 days the cow is picking at hay and drinking some water. She is sticking close to the barn, but is moving around the lot. Do you want to do any additional diagnostics or change treatments?

19. The rest of the bunch….. • Do you want to do anything for the rest of the herd? • Does geography matter? • Does herd type matter? • Can you clear the carrier state?

20. What if’s……… • What if the cow was down with a PCV of 8? • Would you transfuse her? • Would you treat her? • Would you euthanize her? • Any considerations before?

21. CASE 2

22. Problem: drooling, respiratory noise • Signalment: 6-month-old crossbred steer • History: 10 calves (including patient) were weaned, vaccinated, castrated, and dehorned if necessary approximately 2 weeks prior. The calf did not eat as well as expected yesterday. Today it is anorexic and honks on inspiration. • Environment: June in central Missouri. Herd composed of 50 cow/calf pairs on fescue pasture. Calves get some supplemental grain. University of Missouri #

23. Appearance Body condition score 4/9 Normal abdominal contour Behavior Mildly distressed Gait and posture Head and neck extended Urine analysis None caught TPR Temperature – 104.8 ºF Pulse – 80 bpm Respiratory rate – 56 bpm Physical Examination

24. Rumen Normal stratification Pings No pings Lymph Nodes prefemoral – normal prescapular – normal Lung auscultation Difficult to auscult Honking on inspiration Open mouth breathing Heart auscultation Rhythm - regular Intensity - normal Sounds – no murmurs or arrhythmias Jugular vein Normal Cervical skin tent < 2 seconds Physical Examination – left side

25. Pings No pings Seccussion No fluid sloshing Ballotment normal Lymph nodes Prefemoral – normal Prescapular - normal Lung auscultation Difficult to auscult Honking on inspiration Open mouth breathing Heart auscultation Rhythm – regular Intensity – normal Sounds – no murmurs or arrhythmias Jugular vein Normal Cervical skin tent < 2 seconds Physical Examination – right side

26. Abdominal pain None present Skin normal Extremities normal Musculoskeletal normal Head Ocular discharge - none Eye examination – mild scleral injection Nasal discharge – whitish/yellow, fetid Mucous membrane color - pale Mouth Teeth – normal Hypersalivation Neck – large, painful larynx Physical Examination

27. Mammary gland Inflammation NA Strip cup NA California mastitis test NA Rectal palpation NA Feces normal Physical Examination Problem list

28. Problem list • Fever • Tachypnea • Inspiratory noise • Head and neck extended • Open mouth breathing • Fetid breath • Nasal and oral discharge • Scleral injection Prioritized list of differentials

29. Differential diagnosis • Tachypnea, inspiratory noise, head and neck extended, open mouth breathing, fetid breath, nasal discharge, salivation, swollen larynx with pain • Upper airway disease • Necrotic laryngitis – Fusobacterium necrophorum • Laryngeal trauma – abscess or edema • Viral laryngitis – IBR • Actinobacillosis • Fever, scleral injection • Inflammation, infection Initial diagnostic and treatment plan

30. No diagnostics Save money for treatment Endoscopy Radiographs CBC Antibiotics Florfenicol 9 mg/lb IM EOD Anti inflammatory Flunixin meglumine 1.1mg/kg IV SID – BID Diagnostic plan Treatment plan

31. Update – After 48 hours the steer is no longer honking and less dyspneic. The respiratory rate is still elevated and the breath is still somewhat foul smelling. Do you want to do any additional diagnostics or change treatments?

32. Drug Options • Florfenicol • Ceftiofur • Tulathromycin • Tilmicosin • Danofloxacin • Tetracycline • Penicillin • Sulfonimides

33. Case 3

34. Problem: respiratory distress • Signalment: Weaned crossbred beef steer • History: Calf was purchased at a sale barn in northern Missouri with 49 other calves. It was transported to a small feedlot in west central MO where it was vaccinated on arrival. Previous health and vaccine information unknown. Calf pulled for treatment this morning. • Environment: 1000 animal feedyard. No testing done. Calves are routinely purchased and combined into muti-source pens. University of Missouri #

35. Dyspnea

36. Appearance Body condition score 5/9 Gant Behavior Depressed Gait and posture Head and neck extended Urine analysis None caught TPR Temperature – 105.4 ºF Pulse – 76 bpm Respiratory rate – 54 bpm Physical Examination

37. Rumen Normal stratification Pings No pings Lymph Nodes prefemoral – normal prescapular - normal Lung auscultation Loud and harsh Crackles and wheezes Rapid, shallow breaths Heart auscultation Rhythm - regular Intensity - normal Sounds – no murmurs or arrhythmias Jugular vein Normal Cervical skin tent 4 seconds Physical Examination – left side

38. Pings No pings Seccussion No fluid sloshing Ballotment normal Lymph nodes Prefemoral – normal Prescapular - normal Lung auscultation Loud and harsh Crackles and wheezes Rapid, shallow breaths Heart auscultation Rhythm – regular Intensity – normal Sounds – no murmurs or arrhythmias Jugular vein Normal Cervical skin tent 4 seconds Physical Examination – right side

39. Abdominal pain None present Skin normal Extremities normal Musculoskeletal normal Head Ocular discharge - mucopurulent Eye examination - normal Nasal discharge - mucopurulent Mucous membrane color - pale Teeth - normal Physical Examination

40. Mammary gland Inflammation NA Strip cup NA California mastitis test NA Rectal palpation NA Feces normal Physical Examination Problem list

41. Problem list • Fever • Tachypnea • Ocular and nasal discharge • Head and neck extended • Rapid shallow breathing • Abnormal lung sounds Prioritized list of differentials

42. Differential diagnosis • Tachypnea; ocular and nasal discharge; head and neck extension; rapid, shallow breathing; abnormal lung sounds • Pneumonia • Viral • BRSV, IBR, PI3 • Bacterial • Manheimia haemolytica, Histophilus somnii, Pasturella multocida • Fever • Inflammation, infection Initial diagnostic and treatment plan

43. None save money for treatment Arterial blood gas CBC Radiographs Antibiotics and Anti inflammatory Resflor gold Florfenicol 40 mg/kg Flunixin meglumine 2.2 mg/kg IV Dosed at 6ml/100 lbs SQ Diagnostic plan Treatment plan

44. Interpretationshould you so choose to run tests • CBC Neutrophilia – inflammatory disease Neutropenia – inflammatory disease, endotoxemia Left shift Toxic change in neutrophils Hyperfibrinogenemia – inflammatory disease

45. Update – six hours after the initial treatment the calf is noticeably improved. The calf’s temperature is 102.0 F, respiratory rate and effort are within normal limits. The calf is starting to eat and drink. Auscultation still reveals abnormal lung sounds. Do you want to do any additional diagnostics or change treatments?

46. Case 4

47. Problem: Sick • Signalment: 7-year-old Holstein bull • History: ADR for approximately 2 weeks. Treated with antibiotics (several), flunixin meglumine, and several additional substances with no response. • Environment: Bull resides on Amish farm. Used to breed cows for the owner and several neighbors. University of Missouri #

48. Appearance Body condition score 3/5 Behavior QAR Gait and posture Slight arch to back Urine analysis None caught TPR Temperature – 102.5 ºF Pulse – 92 bpm Respiratory rate – 32 bpm Physical Examination

49. Rumen Decreased fill Pings No pings Lymph Nodes prefemoral – normal prescapular – sl. enlarged Lung auscultation normal breath sounds Heart auscultation Rhythm - UTD Intensity - UTD Sounds – abnormal Jugular vein Distended with pulses Cervical skin tent 5 seconds Physical Examination – left side

50. Pings No pings Seccussion No fluid sloshing Ballotment normal Lymph nodes Prefemoral – normal Prescapular – sl. enlargement Lung auscultation Normal breath sounds Heart auscultation Rhythm – UTD Intensity – UTD Sounds – abnormal Jugular vein Distended with pulses Cervical skin tent 5 seconds Physical Examination – right side