{"id":7325,"date":"2023-10-12T17:50:02","date_gmt":"2023-10-12T20:50:02","guid":{"rendered":"https:\/\/www.ufrgs.br\/lacvet\/?p=7325"},"modified":"2023-11-01T11:04:21","modified_gmt":"2023-11-01T14:04:21","slug":"caso-clinico-179y8","status":"publish","type":"post","link":"https:\/\/www.ufrgs.br\/lacvet\/cc_interativos\/caso-clinico-179y8\/","title":{"rendered":"Caso Cl\u00ednico 179Y8"},"content":{"rendered":"
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Identifica\u00e7\u00e3o<\/strong><\/p>\n\t\t\t

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Esp\u00e9cie: Canina
Ra\u00e7a: Spitz Alem\u00e3o
Idade: 11 anos
Sexo: macho
Peso: 2,4 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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H\u00e1 1 m\u00eas o paciente anda curvado e n\u00e3o quer caminhar; n\u00e3o consegue ficar em p\u00e9 (cai sempre que tenta). Perdeu movimento dos membros posteriores h\u00e1 dois dias. Apresentava v\u00f4mito h\u00e1 1 dia, com aspecto de espuma rosa (tutor n\u00e3o identificou como sangue). As fezes estavam moles (tutor n\u00e3o identificou como diarreia). N\u00e3o tomava \u00e1gua desde a manh\u00e3 do atendimento (dia 0). Paciente mora em casa, tendo contato com 3 c\u00e3es h\u00edgidos.<\/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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Identificados problemas dent\u00e1rios (c\u00e1lculo, gengivite, periodontite), dor abdominal moderada \u00e0 palpa\u00e7\u00e3o, dor na regi\u00e3o paravertebral cervical (ao redor de C3). Observada dificuldade respirat\u00f3ria.<\/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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Ultrassonografia (dia 1)<\/strong><\/p>\n\n\n\n

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  • Parede da bexiga espessada e levemente irregular.<\/li>\n\n\n\n
  • Rins com contornos levemente irregulares e com redu\u00e7\u00e3o da rela\u00e7\u00e3o corticomedular (indicativo de nefropatia).<\/li>\n<\/ul>\n\n\n\n

    Radiografia (dia 7)<\/strong><\/p>\n\n\n\n

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    • Altera\u00e7\u00f5es indicativas de edema pulmonar inicial e\/ou broncopneumonia.<\/li>\n\n\n\n
    • Aumento da silhueta card\u00edaca.<\/li>\n\n\n\n
    • Trajeto traqueal com deslocamento dorsal e lateral na por\u00e7\u00e3o tor\u00e1cica e l\u00famen diminu\u00eddo na regi\u00e3o de bifurca\u00e7\u00e3o dos br\u00f4nquios principais.<\/li>\n\n\n\n
    • Espondilose ventral no segmento toracolombar.<\/li>\n\n\n\n
    • Mineraliza\u00e7\u00e3o das cartilagens costais.<\/li>\n\n\n\n
    • Ves\u00edcula urin\u00e1ria moderadamente distendida.<\/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

      <\/span><\/div>\n\t\t<\/div>\n\t\t\t
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      Dia 0: paciente foi internado e medicado com amoxilina\/clavulanato de pot\u00e1ssio (antibi\u00f3tico de amplo espectro), tramadol (opioide), maropitant (antiem\u00e9tico) e omeprazol (redutor de secre\u00e7\u00e3o g\u00e1strica).<\/p>\n\n\n\n

      Dia 1: com base nos resultados dos primeiros exames laboratoriais, foi prescrito lactulona (para reduzir a concentra\u00e7\u00e3o de ureia) e hidr\u00f3xido de alum\u00ednio (quelante de f\u00f3sforo).<\/p>\n\n\n\n

      Dia 7: com base no exame radiogr\u00e1fico, foi administrado cloridrato de benazepril (hipotensor). As dificuldades respirat\u00f3rias do paciente diminu\u00edram, mas n\u00e3o houve melhora completa. Para as \u00falceras na boca, foi utilizado isetionato de hexamidina e cloridrato de tetraca\u00edna.<\/p>\n\n\n\n

      Dia 30: alta hospitalar com indica\u00e7\u00e3o de soro subcut\u00e2neo uma vez por semana. Tutor n\u00e3o retornou com o paciente ap\u00f3s o dia 30.<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

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

      <\/span><\/div>\n\t\t<\/div>\n\t\t\t
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      <\/td>Dia 1<\/strong><\/td>Dia 5<\/strong><\/strong><\/td>Dia 7<\/strong><\/strong><\/td><\/tr>
      pH (7,351-7,443)<\/td>7,18\u2193<\/mark><\/td>7,37<\/a><\/td>7,30<\/td><\/tr>
      pCO2<\/sub> (33,6-41,2 mmHg)<\/td>40,4<\/td>32,0\u2193<\/mark><\/td>41,5\u2191<\/mark><\/td><\/tr>
      pO2<\/sub> (47,9-56,3 mmHg)<\/td>40,1\u2193<\/mark><\/td>39,0\u2193<\/mark><\/td>32,2\u2193<\/mark><\/td><\/tr>
      BEecf (-3 a 2 mmol\/L)<\/td>-13,2\u2193<\/mark><\/td>-7,0\u2193<\/mark><\/td>-6,4\u2193<\/mark><\/td><\/tr>
      HCO3<\/sub> (21-25 mmol\/L)<\/td>15,1\u2193<\/mark><\/td>18,3\u2193<\/mark><\/td>20,0\u2193<\/mark><\/td><\/tr>
      tCO2<\/sub> (mmol\/L)<\/td>16,3<\/td>19,2<\/td>21,3<\/td><\/tr>
      sO2<\/sub> (%)<\/td>58,4<\/td>70,9<\/td>53,1<\/td><\/tr>
      Na (140-155 mmol\/L)<\/td>163,6\u2191<\/mark><\/td>159,9\u2191<\/mark><\/td>155,2<\/td><\/tr>
      K (3,5-5,7 mmol\/L)<\/td>4,5<\/td>3,71<\/td>4,9<\/td><\/tr>
      iCa (1,3-1,5 mmol\/L)<\/td>1,44<\/td>1,26\u2193<\/mark><\/td>1,24\u2193<\/mark><\/td><\/tr>
      Cl (109-122 mmol\/L)<\/td>125,4\u2191<\/mark><\/td>123,1\u2191<\/mark><\/td>116,2<\/td><\/tr>
      Anion gap<\/em> (12-25 mmol\/L)<\/td>27,6\u2191<\/mark><\/td>22,3<\/td>23,9<\/td><\/tr><\/tbody><\/table><\/figure>\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><\/td>Dia <\/strong>1<\/strong><\/td>Dia <\/strong>5<\/strong><\/td>Dia <\/strong>12<\/strong><\/td>Dia <\/strong>22<\/strong><\/td><\/tr>
      Eritr\u00f3citos (5,5-8,5 milh\u00f5es\/\u00b5L)<\/td>5,0\u2193<\/mark><\/td>3,8\u2193<\/mark><\/td>3,0\u2193<\/mark><\/td>2,5\u2193<\/mark><\/td><\/tr>
      Hemat\u00f3crito (37-55%)<\/td>36\u2193<\/mark><\/td>27\u2193<\/mark><\/td>23\u2193<\/mark><\/td>19\u2193<\/mark><\/td><\/tr>
      Hemoglobina (12-18 g\/dL)<\/td>12,2<\/td>9,2\u2193<\/mark><\/td>7,2\u2193<\/mark><\/td>6,1\u2193<\/mark><\/td><\/tr>
      VCM (60-77 fL)<\/td>71,9<\/td>71,4<\/td>76,4<\/td>76,0<\/td><\/tr>
      CHCM (32-36%)<\/td>33,9<\/td>34,1<\/td>31,3\u2193<\/mark><\/td>32,1<\/td><\/tr>
      Plaquetas<\/strong><\/td>\u00a0<\/td>\u00a0<\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
      Quantidade (200-500 \u00d7103<\/sup>\/\u00b5L)<\/td>620\u2191<\/mark><\/td>460<\/td>500<\/td>418<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

      Dia 5: neutr\u00f3filos t\u00f3xicos (+2) e mon\u00f3citos ativados.
      Dias 12 e 22: mon\u00f3citos ativados.<\/p>\n\n\n\n

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      Leucograma<\/strong><\/td>Dia 1<\/strong><\/td>Dia 5<\/strong><\/td>Dia 12<\/strong><\/td>Dia 22<\/strong><\/td><\/tr>
      Leuc\u00f3citos totais (6.000-17.000\/\u00b5L)<\/td>16.500<\/td>44.200\u2191<\/mark><\/td>48.500\u2191<\/mark><\/td>14.900<\/td><\/tr>
      Miel\u00f3citos (0\/\u00b5L)<\/td>0<\/td>0<\/td>0<\/td>0<\/td><\/tr>
      Metamiel\u00f3citos (0\/\u00b5L)<\/td>0<\/td>0<\/td>0<\/td>0<\/td><\/tr>
      Neutr. bast. (<300\/\u00b5L)<\/td>0<\/td>442\u2191<\/mark><\/td>0<\/td>0<\/td><\/tr>
      Neutr. seg. (3.000-11.500\/\u00b5L)<\/td>11.880\u2191<\/mark><\/td>39.780\u2191<\/mark><\/td>\u00a045.105\u2191<\/mark><\/td>13.410\u2191<\/mark><\/td><\/tr>
      Bas\u00f3filos (<200\/\u00b5L)<\/td>0<\/td>0<\/td>0<\/td>0<\/td><\/tr>
      Eosin\u00f3filos (100-1.250\/\u00b5L)<\/td>495<\/td>0\u2193<\/mark><\/td>0\u2193<\/mark><\/td>149<\/td><\/tr>
      Mon\u00f3citos (150-1.350\/\u00b5L)<\/td>3.465\u2191<\/mark><\/td>3.094\u2191<\/mark><\/td>2.425\u2191<\/mark><\/td>894<\/td><\/tr>
      Linf\u00f3citos (1.000-4.800\/\u00b5L)<\/td>660\u2193<\/mark><\/td>884\u2193<\/mark><\/td>970\u2193<\/mark><\/td>447\u2193<\/mark><\/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 1<\/strong><\/td>Dia 5<\/strong><\/td>Dia 8<\/strong><\/td>Dia 12<\/strong><\/td>Dia 22<\/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>
      Prote\u00ednas totaisB<\/sup> (60-80 g\/L)<\/td>78<\/td>60<\/td>\u00a0n.d.<\/td>\u00a0n.d.<\/td>70<\/td><\/tr>
      Prote\u00ednas totaisC<\/sup> (54-71 g\/L)<\/td>\u00a0n.d.<\/td>\u00a0n.d.<\/td>\u00a0n.d.<\/td>\u00a0n.d.<\/td>\u00a0n.d.<\/td><\/tr>
      Albumina (26-33 g\/L)<\/td>28<\/td>\u00a0n.d.<\/td>\u00a0n.d.<\/td>\u00a0n.d.<\/td>24\u2193<\/mark><\/td><\/tr>
      Globulinas (27-44 g\/L)<\/td>\u00a050\u2191<\/mark><\/td>\u00a0n.d.<\/td>\u00a0n.d.<\/td>\u00a0n.d.<\/td>36<\/td><\/tr>
      Ureia (21-60 mg\/dL)<\/td>602\u2191<\/mark><\/td>209\u2191<\/mark><\/td>224\u2191<\/mark><\/td>378\u2191<\/mark><\/td>447\u2191<\/mark><\/td><\/tr>
      Creatinina (<1,4 mg\/dL)<\/td>2,8\u2191<\/mark><\/td>2,9\u2191<\/mark><\/td>2,7\u2191<\/mark><\/td>1,9\u2191<\/mark><\/td>6,4\u2191<\/mark><\/td><\/tr>
      C\u00e1lcio (9,0-11,3 mg\/dL)<\/td>\u00a0n.d.<\/td>\u00a0n.d.<\/td>8,6\u2193<\/mark><\/td>\u00a0n.d.<\/td>9,7<\/td><\/tr>
      F\u00f3sforo (2,6-6,2 mg\/dL)<\/td>\u00a0n.d.<\/td>\u00a0\u00a0n.d.<\/td>6,5\u2191<\/mark><\/td>\u00a0n.d.<\/td>16,7\u2191<\/mark><\/td><\/tr>
      FA (<156 U\/L)<\/td>39<\/td>\u00a0n.d.<\/td>\u00a0n.d.<\/td>\u00a0n.d.<\/td>\u00a0n.d.<\/td><\/tr>
      ALT (<102 U\/L)<\/td>96<\/td>\u00a0n.d.<\/td>\u00a0n.d.<\/td>\u00a0n.d.<\/td>165\u2191<\/mark><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

      B<\/sup>Estimadas por refratometria; C<\/sup>Determinadas por espectrofotometria<\/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 2<\/strong><\/td><\/tr>
      M\u00e9todo de coletaA<\/sup><\/td>cat<\/td><\/tr>
      Sedimento urin\u00e1rioB<\/sup><\/strong><\/td><\/td><\/tr>
      C\u00e9lulas epiteliais<\/td>n.d.<\/td><\/tr>
      Cilindros<\/td>n.d.<\/td><\/tr>
      Hem\u00e1cias<\/td>n.d.<\/td><\/tr>
      Leuc\u00f3citos<\/td>n.d.<\/td><\/tr>
      Bacteri\u00faria<\/td>n.d.<\/td><\/tr>
      Outros<\/td>Fosfato triplo (1+)<\/td><\/tr>
      Exame qu\u00edmico<\/strong><\/td>\u00a0<\/td><\/tr>
      pH (5,5-7,0)<\/td>8,0\u2191<\/mark><\/td><\/tr>
      Corpos cet\u00f4nicosC<\/sup><\/td>n.d.<\/td><\/tr>
      GlicoseD<\/sup><\/td>n.d.<\/td><\/tr>
      BilirrubinaE<\/sup><\/td>n.d.<\/td><\/tr>
      Urobilinog\u00eanio (<1 mg\/dL)<\/td>n.d.<\/td><\/tr>
      Prote\u00ednaF<\/sup><\/td>+\u2191<\/mark><\/td><\/tr>
      SangueG<\/sup><\/td>n.d.<\/td><\/tr>
      RPCUH<\/sup><\/td>1,13\u2191<\/mark><\/td><\/tr>
      Exame f\u00edsico<\/strong><\/td><\/td><\/tr>
      Dens. espec. (1,015-1,045)<\/td>1,018 \u00a0<\/td><\/tr>
      Cor<\/td>Amarela escura<\/td><\/tr>
      Consist\u00eancia<\/td>Fluida<\/td><\/tr>
      Aspecto<\/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