Mitzie was brought to her veterinarian 3 weeks ago for a routine examination. Blood work was submitted as a pre-screen for a proposed dental procedure. Blood work: BUN 106, creatinine 4.1, PO4 10.8, Ca 11.9, K 6.1, cholesterol 330, amylase 3,470, lipase 757, RBC 5.3, PCV 41%.
The referring DVM was concerned about renal disease and possible pancreatitis and/or neoplasia. Mitzie was admitted and treated with 700–900 ml 0.9% NaCl per day for three days, plus Amphojel and cefazolin BID. During hospitalization, she ate poorly and vomited repeatedly.
Blood work 6 days later: BUN 75, creatinine 4.0, PO4 12.1, RBC 4.3, PCV 33%. Ca, K, cholesterol, amylase, and lipase were within normal limits. Sent home on Amphojel and amoxicillin 400 mg BID.
The owners report that when Mitzie returned home she continued to vomit and refuse food. She bumped into objects in the house, was very ataxic, collapsed frequently, got stuck in corners, and appeared to circle to the left.
Repeat blood work 1 week ago: BUN 75, creatinine 3.1. Given 350 ml 0.9% NaCl IV. Medications discontinued. She continued to show signs of disorientation, weakness, and inappetence.
Physical Examination
Alert and responsive to touch or loud noises. Stands with left elbow rotated axially. Very ataxic and weak in all four limbs but worse in the front. Collapses with thoracic limbs abducted.
Wanders restlessly in the exam room, runs into objects, and gets into corners and pauses before moving on.
Eyes: cloudy lenses OU. Severe tartar and moderate gingivitis.
HR = 150, irregular rhythm. Panting.
No menace response, normal PLRs, anisocoria (OD > OS), positional horizontal nystagmus with the fast phase to the right.
All tendons were hyporeflexic. Conscious proprioception absent in the front limbs and depressed in the hind limbs.
Problems
Historical renal insufficiency
Ataxia
Visual impairment
Nystagmus
Arrhythmia
Plans and Progress Notes
First Day
Problem 1 — Historical renal insufficiency. S/O: Most recent blood work shows elevated BUN and creatinine. A: Renal parameters are more critical at this time. P: CBC, chem panel, lipase, urinalysis with P:C ratio, blood pressure measurement, and abdominal ultrasound. Offer water q4h, feed k/d disguised with something tastier. Carry outside to urinate.
Problem 2 — Ataxia. S/O: Very ataxic and weak in all four limbs. Collapses with thoracic limbs abducted. Hyporeflexic tendon responses and absent CPs in thoracic limbs, diminished in hind. A: Appears due to weakness; could be uremia or neurologic. Metabolic problems take priority. P: See Problem 1.
Problem 3 — Visual impairment. S/O: No menace response, normal PLRs, intact blink response. A: Acute onset of visual impairment associated with renal insult makes us suspicious of retinal hemorrhage as a result of hypertension from renal disease. P: Ophthalmology consult to R/O a problem of the eye.
Problem 4 — Nystagmus. S/O: Positional horizontal nystagmus, fast phase to the right. Anisocoria OD > OS. A: Could be primary neurological or metabolic encephalopathy. P: See Problem 1.
Problem 5 — Arrhythmia. S/O: Questionable arrhythmia on cardiac auscultation. P: Cardiology consultation. Thoracic radiographs.
Second Day
Problem 1. S/O: CBC: RBC 5.92, PCV 45%, WBC 18,300 — mild neutrophilia and monocytosis. Chem panel: BUN 124, creatinine 6.5, PO4 14.5, Ca 13.2, K 6.1, cholesterol 385. Ultrasound: bilateral abnormal renal architecture, left renal cortical cysts, mineralized left adrenal gland, mild hepatomegaly. A: Chronic renal failure. The mineralized adrenal gland results from PO4/Ca imbalances causing secondary hyperparathyroidism. Hypertension could cause many of Mitzie’s signs. P: Urinalysis with P:C ratio and blood pressure. Start 0.9% NaCl at 30 ml/hr IV. Start cottage cheese and rice diet. Repeat blood work after overnight fluids. Rename to Problem 6: Chronic renal failure.
Problem 5. S/O: Thoracic radiographs: prominent aorta. Cardiology consult: thickened left ventricle, intermittent tachycardia and second degree AV block. A: Cardiac arrhythmia may be consistent with metabolic disease. LV thickening and prominent aorta could be explained by hypertension. P: Correct electrolytes and look for hypertension.
Third Day
Problem 6. S/O: Lethargic, weak, alert. No menace bilaterally. T = 101.4°F, Wt = 10.8 kg. BUN 125, creatinine 4.9, PO4 12.7, Ca 10.7, K 5.5, cholesterol 330. Urinalysis: SG 1.011, 1+ protein, urine P:C = 2.17. Blood pressure (Dinamap): systolic 185, diastolic 133, mean 153 mmHg. Doppler confirmed systolic 190 mmHg. P: Increase fluids to 2× maintenance. Continue mannitol at 1 mg/kg/min. Recheck kidney panel. Start phosphate binder with meals.
New Problem 7: Hypertension. A: Severe hypertension explains ataxia, central neurologic signs, and retinal hemorrhages. P: Start diltiazem 1.5 mg/kg PO TID. Recheck BP tomorrow. If no improvement, increase to 2 mg/kg.
Problem 2. A: Ataxia likely due to weakness and possibly brain hemorrhage from hypertension. May be permanent damage. P: Control hypertension.
Problem 3. A: Bilateral retinal hemorrhages from severe hypertension causing acute blindness. Treatment of hypertension may restore vision but could be permanent. Rename to Problem 8: Retinal hemorrhages (bilateral).
Fourth Day
Problem 6. S/O: Eating better, less weak, possibly less ataxic. Still no menace. BUN 61, Cr 3.1, Phos 8.2. BP still 190/130 mmHg. A: Renal values decreased with diuresis but will likely increase again. P: Begin tapering fluids tonight. Discontinue mannitol.
Problem 7. A: BP still uncontrolled. P: Increase diltiazem to 2 mg/kg TID (22.5 mg PO TID). Recheck tomorrow. If no change, switch to prazosin.
Problem 2. A: Ataxia seems to be resolving but she is also getting stronger. P: Neurology consult.
Fifth Day
Problem 7. S/O: P = 144, RR = 18. Repeat systolic BP 185 mmHg (Doppler). Appetite good. Much stronger. Still no menace. Neurology: less weak but ataxia the same. A: Hypertension not improved. P: Switch to prazosin 0.5 mg PO TID. Recheck pressures in the morning. Send home tomorrow, recheck Tuesday.
Problem 6. P: Taper fluids to maintenance, then ½ maintenance tonight, discontinue tomorrow. Send home on 150–200 ml SQ LRS BID, Basalgel ½ capsule (250 mg) in food BID, Pepcid AC ½ tab (5 mg) PO SID. Recheck kidney values Tuesday. Taught owners to administer SQ fluids.
Sixth Day
Problem 7. S/O: Stronger, eating and drinking well. Systolic 195, diastolic 133, mean 155 mmHg. Still no menace, very ataxic but not weak. A: Hypertension not improved. P: Increase prazosin to 1 mg TID PO. Send home. Recheck Tuesday.
Discharge Summary
Mitzie was admitted due to acute onset of marked ataxia and apparent blindness. She was referred to Medicine due to marked azotemia, retinal hemorrhages, and suspected hypertension. Systemic arterial blood pressure was 195/133 mmHg, which was uncontrolled during entire visit despite switching medications and increasing dosages. Diuresis decreased azotemia. Sent home on Basalgel, SQ LRS, Pepcid AC, and prazosin to help control symptoms.
Two Days Later
Patient is hypertensive. BP at 8:30 AM: systolic 177, diastolic 133, mean 156 mmHg.