{"id":6303,"date":"2023-07-04T19:06:06","date_gmt":"2023-07-04T22:06:06","guid":{"rendered":"https:\/\/www.ufrgs.br\/lacvet\/?p=6303"},"modified":"2024-02-15T15:04:01","modified_gmt":"2024-02-15T18:04:01","slug":"caso-clinico-177pn","status":"publish","type":"post","link":"https:\/\/www.ufrgs.br\/lacvet\/cc_interativos\/caso-clinico-177pn\/","title":{"rendered":"Caso Cl\u00ednico 177PN"},"content":{"rendered":"
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Identifica\u00e7\u00e3o<\/strong><\/p>\n\t\t\t

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Esp\u00e9cie: Canina
Ra\u00e7a: SRD
Idade: 6 anos
Sexo: f\u00eamea
Peso: 16,2 kg<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

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Anamnese<\/strong><\/p>\n\t\t\t

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A paciente foi atendida para a realiza\u00e7\u00e3o de um check-up<\/em> de rotina. A tutora relatou que o animal apresentava incontin\u00eancia urin\u00e1ria e alguns epis\u00f3dios de poli\u00faria (que v\u00eam ocorrendo h\u00e1 cerca de 4 meses). A paciente \u00e9 castrada, mora em casa e tem contato com mais outros 4 c\u00e3es h\u00edgidos. A paciente faz uso de verm\u00edfugo 3 vezes ao ano, tem uma alimenta\u00e7\u00e3o constitu\u00edda de ra\u00e7\u00e3o (n\u00e3o foi especificada a marca nem a frequ\u00eancia de oferta da ra\u00e7\u00e3o). A tutora relatou hiporexia e hipodipsia juntamente com epis\u00f3dios de polidipsia.<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

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Exame f\u00edsico<\/strong><\/p>\n\t\t\t

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Escore corporal: 5 (ref.: 5, escala de 1-9)
Escore mental: alerta
Temperatura retal: 38,9\u00b0C (ref.: 37,5\u201339,5)
Normo-hidratada; mucosas normocoradas
Tempo de preenchimento capilar: < 2 segundos (ref.: < 2)
Frequ\u00eancia card\u00edaca: 180 bpm (ref.: 160\u2013240)
Glicemia (glicos\u00edmetro): 100 mg\/dL (ref.: 65-118)
Linfonodos submandibulares aumentados; evid\u00eancia de sopro card\u00edaco no lado esquerdo.<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

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Exames complementares<\/strong><\/p>\n\t\t\t

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Dia 12<\/strong><\/p>\n\n\n\n

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  • Radiografia tor\u00e1cica: silhueta card\u00edaca, campos pulmonares, trajeto traqueal e demais estruturas tor\u00e1cicas dentro dos padr\u00f5es da normalidade radiogr\u00e1fica.<\/li>\n\n\n\n
  • Ultrassonografia abdominal:\n
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    • Bexiga com paredes lisas e normoespessas, forma\u00e7\u00e3o muito t\u00eanue de \u201cparede dupla\u201d, indicando edema muito discreto.<\/li>\n\n\n\n
    • Rins sim\u00e9tricos, tamanho normal, com contornos irregulares com visualiza\u00e7\u00e3o de \u00e1rea fina hiperecog\u00eanica em formato de cunha compat\u00edvel com pequena \u00e1rea de infarto. Rela\u00e7\u00e3o cortical\/medular aumentada, jun\u00e7\u00e3o corticomedular pouco definida e irregular. Par\u00eanquima cortical hipoecog\u00eanico e medular normoecog\u00eanica. Sem evid\u00eancia de dilata\u00e7\u00e3o ou urolit\u00edases em pelve renal.<\/li>\n\n\n\n
    • Adrenais com par\u00eanquimas hipoecog\u00eanicos, contornos lisos regulares, apontando uma hiperplasia adrenal. Ba\u00e7o com dimens\u00f5es normais e par\u00eanquima inalterado.<\/li>\n\n\n\n
    • F\u00edgado com dimens\u00f5es normais, par\u00eanquima hipoecog\u00eanico homog\u00eaneo e discreta dilata\u00e7\u00e3o de vasos portais e leve a moderada de veias hep\u00e1ticas.<\/li>\n\n\n\n
    • Ves\u00edcula biliar repleta, paredes lisas e normoespessas.<\/li>\n\n\n\n
    • Est\u00f4mago com reple\u00e7\u00e3o m\u00ednima, paredes hipoecog\u00eanicas espessadas em fundo g\u00e1strico, com estratifica\u00e7\u00e3o mural pouco definida.<\/li>\n\n\n\n
    • Segmentos intestinas delgados com paredes hipoecog\u00eanicas.<\/li>\n<\/ul>\n<\/li>\n\n\n\n
    • Ecodopplercardiograma: escape da veia pulmonar, insufici\u00eancia mitral discreta e aumento discreto de \u00e1trio esquerdo. Demais aspectos dentro da normalidade.<\/li>\n<\/ul>\n\n<\/div>\n\t\t<\/div>\n\n
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      Tratamento e evolu\u00e7\u00e3o<\/strong><\/p>\n\t\t\t

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      Dia 15: <\/strong>O tutor relatou v\u00f4mito e desaparecimento da incontin\u00eancia urin\u00e1ria. Constatado que o animal estava em bom estado geral, com temperatura de 39,4\u00b0C (ref.: 37,5\u201139,5) e glicemia (glicos\u00edmetro) de 133 mg\/dL (ref.: 65\u2011118). Solicitada investiga\u00e7\u00e3o de fun\u00e7\u00e3o end\u00f3crina devido \u00e0 hiperplasia das adrenais, por\u00e9m n\u00e3o foi confirmado nenhuma patologia. Aplicado citrato de maropitant (antiem\u00e9tico) e iniciado o tratamento com cloridrato de ranitidina (preven\u00e7\u00e3o de \u00falceras, devido ao quadro de gastrite), cloridrato de benazepril (hipotensor, devido a insufici\u00eancia de v\u00e1lvula mitral) e \u00f4mega\u20113.<\/p>\n\n\n\n

      Dia 25: <\/strong>N\u00e3o apresentava mais v\u00f4mito, por\u00e9m o tutor relatou emagrecimento e diminui\u00e7\u00e3o de apetite. Realizada fluidoterapia, com a administra\u00e7\u00e3o de Ringer-lactato (solu\u00e7\u00e3o isot\u00f4nica, alcaliniza\u00e7\u00e3o e reposi\u00e7\u00e3o eletrol\u00edtica) via subcut\u00e2nea. Aplicado, novamente, citrato de maropitant e mantido o tratamento com cloridrato de ranitidina, cloridrato de benazepril e \u00f4mega\u20113. Adicionado ao tratamento o cloridrato de metoclopramida (preven\u00e7\u00e3o de disfun\u00e7\u00f5es digestivas).<\/p>\n\n\n\n

      Dia 26: <\/strong>Fluidoterapia e aplica\u00e7\u00e3o de citrato de maropitant. Continuado o tratamento com cloridrato de benazepril e \u00f4mega\u20113.<\/p>\n\n\n\n

      Dia 43: <\/strong>Tratamento com cloridrato de benazepril e \u00f4mega\u20113.<\/p>\n\n\n\n

      Dia 53: <\/strong>Fluidoterapia (Ringer-lactato, via SC). Recomendada a realiza\u00e7\u00e3o de fluidoterapia em casa, duas vezes por semana e mantidos os tratamentos com cloridrato de benazepril e \u00f4mega\u20113.<\/p>\n\n\n\n

      Dia 83: <\/strong>Apresentava bom estado geral e obteve ganho de peso nos \u00faltimos 30 dias. Observada a presen\u00e7a de Dipylidium<\/em> sp. nas fezes. Administrado verm\u00edfugo e continuados os tratamentos com fluidoterapia, cloridrato de benazepril e \u00f4mega\u20113.<\/p>\n\n\n\n

      Dia 134: <\/strong>Fluidoterapia, com administra\u00e7\u00e3o de Ringer-lactato (via SC), e aplica\u00e7\u00e3o de citrato de maropitant.<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

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      Hemograma<\/strong><\/p>\n\t\t\t

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      Eritrograma<\/strong><\/strong><\/td>Dia 0<\/strong><\/td>Dia 43<\/strong><\/td><\/tr>
      Eritr\u00f3citos (5,5-8,5 milh\u00f5es\/\u00b5L)<\/td>5,65<\/td>5,47\u2193<\/mark><\/td><\/tr>
      Hemat\u00f3crito (37-55%)<\/td>42<\/td>39<\/td><\/tr>
      Hemoglobina (12-18 g\/dL)<\/td>14,2<\/td>14,1<\/td><\/tr>
      VCM (60-77 fL)<\/td>74,3<\/td>71,3<\/td><\/tr>
      CHCM (32-36%)<\/td>33,8<\/td>36,2\u2191<\/mark><\/td><\/tr>
      Plaquetas<\/strong><\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
      Quantidade (200-500 \u00d7103<\/sup>\/\u00b5L)<\/td>264<\/td>n.d.*<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

      Observa\u00e7\u00f5es: *presen\u00e7a de agrega\u00e7\u00e3o plaquet\u00e1ria; n.d., n\u00e3o determinado.<\/p>\n\n\n\n

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      Leucograma<\/strong><\/td>Dia 0<\/strong><\/td>Dia 43<\/strong><\/td><\/tr>
      Leuc\u00f3citos totais (6.000-17.000\/\u00b5L)<\/td>10.500<\/td>7.200<\/td><\/tr>
      Miel\u00f3citos (0\/\u00b5L)<\/td>0<\/td>0<\/td><\/tr>
      Metamiel\u00f3citos (0\/\u00b5L)<\/td>0<\/td>0<\/td><\/tr>
      Neutr. bast. (<300\/\u00b5L)<\/td>0<\/td>0<\/td><\/tr>
      Neutr. seg. (3.000-11.500\/\u00b5L)<\/td>7.702<\/td>5.040<\/td><\/tr>
      Bas\u00f3filos (<200\/\u00b5L)<\/td>0<\/td>0<\/td><\/tr>
      Eosin\u00f3filos (100-1.250\/\u00b5L)<\/td>633<\/td>360<\/td><\/tr>
      Mon\u00f3citos (150-1.350\/\u00b5L)<\/td>633<\/td>144\u2193<\/mark><\/td><\/tr>
      Linf\u00f3citos (1.000-4.800\/\u00b5L)<\/td>1.583<\/td>1.656<\/td><\/tr><\/tbody><\/table><\/figure>\n\n<\/div>\n\t\t<\/div>\n\n
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      Bioqu\u00edmica sangu\u00ednea<\/strong><\/p>\n\t\t\t

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      <\/td>Dia 0<\/strong><\/td>Dia 25<\/strong><\/td>Dia 43<\/strong><\/td>Dia 83<\/strong><\/td>Dia 134<\/strong><\/td><\/tr>
      Amostra<\/td>soro<\/td>soro<\/td>soro<\/td>soro<\/td>soro<\/td><\/tr>
      Hem\u00f3lise<\/td>ausente<\/td>ausente<\/td>ausente<\/td>ausente<\/td>ausente<\/td><\/tr>
      AnticoagulanteA<\/sup><\/td>nenhum<\/td>nenhum<\/td>nenhum<\/td>nenhum<\/td>nenhum<\/td><\/tr>
      Prote\u00ednas totaisB<\/sup> (60-80 g\/L)<\/td>70<\/td>n.d.<\/td>68<\/td>n.d.<\/td>n.d.<\/td><\/tr>
      Prote\u00ednas totaisC<\/sup> (54-71 g\/L)<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td><\/tr>
      Albumina (26-33 g\/L)<\/td>34\u2191<\/mark><\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td><\/tr>
      Globulinas (27-44 g\/L)<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td><\/tr>
      Ureia (21-60 mg\/dL)<\/td>177\u2191<\/mark><\/td>205\u2191<\/mark><\/td>201\u2191<\/mark><\/td>239\u2191<\/mark><\/td>202\u2191<\/mark><\/td><\/tr>
      Creatinina (<1,4 mg\/dL)<\/td>3,38\u2191<\/mark><\/td>4,25\u2191<\/mark><\/td>4,21\u2191<\/mark><\/td>4,52\u2191<\/mark><\/td>5,17\u2191<\/mark><\/td><\/tr>
      F\u00f3sforo (2,6-6,2 mg\/dL)<\/td>n.d.<\/td>4,8<\/td>n.d.<\/td>6,8\u2191<\/mark><\/td>6,2<\/td><\/tr>
      FA (<156 U\/L)<\/td>35<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td><\/tr>
      ALT (<102 U\/L)<\/td>39<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

      B<\/sup>Estimadas por refratometria; C<\/sup>Determinadas por espectrofotometria; n.d.. n\u00e3o determinado.<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

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      Urin\u00e1lise<\/strong><\/p>\n\t\t\t

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      <\/td>Dia 15<\/strong><\/td>Dia 43<\/strong><\/td>Dia 83<\/strong><\/td>Dia 134<\/strong><\/td><\/tr>
      M\u00e9todo de coletaA<\/sup><\/td>cist<\/td>mic<\/td>mic<\/td>mic<\/td><\/tr>
      Sedimento urin\u00e1rioB<\/sup><\/strong><\/td>\u00a0<\/td>\u00a0<\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
      C\u00e9lulas epiteliais<\/td>escamosas (2)<\/td>escamosas (1)<\/td>escamosas (1), transi\u00e7\u00e3o (1)<\/td>escamosas (1), transi\u00e7\u00e3o (1)<\/td><\/tr>
      Cilindros<\/td>ausente<\/td>ausente<\/td>ausente<\/td>ausente<\/td><\/tr>
      Hem\u00e1cias<\/td>ausente<\/td>ausente<\/td>ausente<\/td>ausente<\/td><\/tr>
      Leuc\u00f3citos<\/td><5<\/td>ausente<\/td>ausente<\/td>ausente<\/td><\/tr>
      Bacteri\u00faria<\/td>ausente<\/td>ausente<\/td>ausente<\/td>ausente<\/td><\/tr>
      Outros<\/td>\u00a0<\/td>\u00a0<\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
      Exame qu\u00edmico<\/strong><\/td>\u00a0<\/td>\u00a0<\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
      pH (5,5-7,0)<\/td>6,0<\/td>6,0<\/td>6,0<\/td>6,5<\/td><\/tr>
      Corpos cet\u00f4nicosC<\/sup><\/td>ausente<\/td>ausente<\/td>ausente<\/td>ausente<\/td><\/tr>
      GlicoseD<\/sup><\/td>ausente<\/td>ausente<\/td>ausente<\/td>ausente<\/td><\/tr>
      BilirrubinaE<\/sup><\/td>ausente<\/td>ausente<\/td>ausente<\/td>ausente<\/td><\/tr>
      Urobilinog\u00eanio (<1 mg\/dL)<\/td>\u22481,0<\/td>\u22481,0<\/td>\u22481,0<\/td>\u22481,0<\/td><\/tr>
      Prote\u00ednaF<\/sup><\/td>+\u2191<\/mark><\/td>++\u2191<\/mark><\/td>+\u2191<\/mark><\/td>ausente<\/td><\/tr>
      SangueG<\/sup><\/td>ausente<\/td>ausente<\/td>ausente<\/td>ausente<\/td><\/tr>
      RPCUH<\/sup><\/td>0,83\u2191<\/mark><\/td>0,32<\/td>0,37<\/td>0,16<\/td><\/tr>
      Exame f\u00edsico<\/strong><\/td>\u00a0<\/td>\u00a0<\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
      Dens. espec. (1,015-1,045)<\/td>1,012\u2193<\/mark><\/td>1,012\u2193<\/mark><\/td>1,012\u2193<\/mark><\/td>1,010\u2193<\/mark><\/td><\/tr>
      Cor<\/td>amarelo<\/td>amarelo claro<\/td>amarelo claro<\/td>amarelo<\/td><\/tr>
      Consist\u00eancia<\/td>fluida<\/td>fluida<\/td>fluida<\/td>fluida<\/td><\/tr>
      Aspecto<\/td>l\u00edmpido<\/td>l\u00edmpido<\/td>l\u00edmpido<\/td>l\u00edmpido<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

      A<\/sup>mic, mic\u00e7\u00e3o natural \u25cf cat, cateteriza\u00e7\u00e3o \u25cf cist, cistocentese \u25cf out, outros (especificar em \u201cObserva\u00e7\u00f5es\u201d)
      B<\/sup>N\u00famero m\u00e9dio de elementos por campo de 400 x
      C<\/sup>tra\u00e7os, \u22485 mg\/dL \u25cf +, \u224815 mg\/dL \u25cf ++, \u224840 mg\/dL \u25cf +++, \u224880 md\/dL \u25cf ++++, \u2265160 mg\/dL
      D<\/sup>tra\u00e7os, \u2248100 mg\/dL \u25cf +, \u2248250 mg\/dL \u25cf ++, \u2248500 mg\/dL \u25cf +++, \u22481000 mg\/dL \u25cf ++++, \u22652000 mg\/dL
      E<\/sup>+, leve \u25cf ++, moderada \u25cf +++, alta
      F<\/sup>+, \u224830 mg\/dL \u25cf ++, \u2248100 mg\/dL \u25cf +++, \u2248300 mg\/dL \u25cf ++++, \u22652000 mg\/dL
      G<\/sup>nh, n\u00e3o hemolisado \u25cf h, hemolisado \u25cf +, leve \u25cf ++, moderada \u25cf +++, alto
      H<\/sup>RPCU, rela\u00e7\u00e3o prote\u00edna\/creatinina urin\u00e1ria (na aus\u00eancia de sedimento ativo)
      – Caninos: <0,2, n\u00e3o protein\u00farico \u25cf 0,2 a 0,5, protein\u00faria lim\u00edtrofe \u25cf >0,5, protein\u00farico
      – Felinos: <0,2, n\u00e3o protein\u00farico \u25cf 0,2 a 0,4, protein\u00faria lim\u00edtrofe \u25cf >0,4, protein\u00farico
      – Equinos: <0,93, n\u00e3o protein\u00farico
      n.d.: n\u00e3o determinado<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

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      Discuss\u00e3o e refer\u00eancias bibliogr\u00e1ficas<\/strong><\/p>\n\t\t\t

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      Devem ser discutidos os achados laboratoriais alterados (referentes a urin\u00e1lise, bioqu\u00edmica sangu\u00ednea e hemograma), estabelecendo as correla\u00e7\u00f5es relevantes com o quadro cl\u00ednico do paciente. N\u00e3o deve ser discutido o tratamento realizado. As altera\u00e7\u00f5es nos achados laboratoriais devem ser justificadas com base nas informa\u00e7\u00f5es contidas na literatura especializada. \u00c9 sugerido organizar a discuss\u00e3o nos seguintes grandes t\u00f3picos:<\/p>\n\n\n\n