Clinical Skills - Blk 4

For best practice, conduct urinalysis in the first ____ minutes.

30

If urine samples cannot be analyzed quickly enough, what should you do?

Immediately refrigerate in a clean, sealed container

Samples should be warmed to room temperature prior to analysis

Mix thoroughly prior to analysis

Patient-side analysis of urine reduces…

Growth or death of bacteria

Cell and cast degradation, especially with low urine specific gravity

Formation of crystals and amorphous material

Breakdown of bilirubin by sunlight

The urinalysis is only complete with all three parts. What are the three parts?

Physical analysis

Chemical analysis

Sediment analysis

What qualities do we measure when performing physical analysis of urine?

Color, clarity, urine specific gravity

What are the benefits of performing a chemical analysis with the IDEXX VetLab UA Analyzer?

Eliminates subjectivity

Reads pads at the correct time

Compensates for background color of urine

Transfers data automatically to the patient record on the IDEXX VetLab Station and VetConnect PLUS

What are the benefits of performing a sediment analysis with the SediVue Dx Urine Sediment Analyzer?

Accurate, consistent, real-time results in 3 minutes

Small sample volume is required

High-quality images are part of the medical record

Automated microscopy standardizes evaluation of urine sediment

Two-way integration:

• Automatically uploads results to the patient record

• Charge capture

What volume is used for sediment analysis with the SediVue Dx Urine Sediment Analyzer

165 microliters

If the SediVue Dx Urine Sediment Analyzer is classified as “None detected”, what does that mean?

Element has not been detected. There are not enough recognizable features to classify.

If the SediVue Dx Urine Sediment Analyzer is classified as “<1/HPF”, what does that mean?

Some features are present, although rare and below the clinical reporting threshold

If the SediVue Dx Urine Sediment Analyzer is classified as “Suspect presence”, what does that mean?

There are some recognizable features of an element (cocci, rods, casts) present; however, there are not enough features, or quantity, to report as “present”

If the SediVue Dx Urine Sediment Analyzer is classified as “Present”, what does that mean?

High confidence in the presence of bacteria in the sample

Red Blood Cells (RBC)

Uniform size, round

No nuclear content visible

Area of central pallor

Smallest cell type

Can look similar to lipids but more uniform in size

Potential crenation (not shown here)

• High USG

• Uniform short projections from cell surface

White blood cells (WBC)

Slightly larger than RBCs

Smaller than nonsquamous epithelial cells

Contain internal cellular structures

• Nuclei

• Granular cytoplasm

Primarily neutrophils but other leukocyte types may be present

What are the two broad categories of epithelial cells?

Squamous

Non-squamous

• Transitional cells

• Renal tubular epithelial cells

Squamous epithelial cells

Larger than RBCs and WBCs and most nonsquamous epithelial cells

Primarily contamination from the external genitalia

Low numbers can be normal (sloughing of old cells)

High numbers may or may not suggest a significant pathological process

Nonsquamous epithelial cells

Low numbers normal due to cell sloughing and turnover

High numbers possible with hyperplasia

• Inflammatory

• Noninflammatory

Air-dried, stained cytology preparation recommended if TCC suspected

What are two broad categories of casts?

Hyaline

Nonhyaline

• Cellular

• Granular

• Waxy

Hyaline casts

Occasional hyaline casts are normal

Low numbers may occur with fever or following strenuous exercise

Dehydration may result in increased numbers

High numbers indicate kidney injury

• Often accompanied by proteinuria

Nonhyaline casts

Cellular casts (rare)

• Renal tubular, red blood cells and white blood cells

Granular casts (common)

• Coarse to fine

Waxy casts

• Well-defined, refractive index

• Final stage of cast progression

Types of crystals

Calcium oxalate dihydrate

Struvite

Ammonium biurate

Bilirubin

Unclassified crystals

Crystals in urine

• Precipitation of various elements

• May or may not occur with uroliths

• May form or dissolve in aged or altered samples

Struvite

Magnesium ammonium phosphate or triple phosphate crystals

Clear, colorless, with coffin-lid shape

Alkaline to slightly acidic urine

Low numbers in healthy dogs

Potential high numbers associated with inflammatory urinary tract disease

Atypical appearance ± variable in number in aged samples

Calcium oxalate dihydrate

Clear, colorless, octahedral, “envelope”

Variable size

Typically found in acidic urine; may see in neutral and alkaline urine

Low numbers in healthy dogs and cats

Commonly a refrigeration artifact

May or may not see with oxalate urolith

Ammonium biurate

Spherules with or without irregular projections

Brown-orange on manual microscopy

Neutral to acidic urine

Not common in healthy dogs and cats, except in dalmations and bulldogs

Associated with portal vascular shunts (congenital or acquired)

Bilirubin

Needle-like

Yellow to brown on manual microscopy

Low numbers may be normal in dogs, especially in concentrated urine

High numbers in nonconcentrated urine support cholestasis

Any presence in cats is abnormal

What are other crystal types?

Calcium oxalate monohydrate

Cystine

Cholesterol

Uric acid

Drug-related

Atypical presentations of reported crystal types

Two broad categories of bacteria

Rods

Cocci

Bacteriuria occurs most commonly due to…

Urinary tract infection

Contamination - during or after collection

What is the gold standard of interpreting bacteriuria?

Urine culture and sensitivity

• Negative test does not rule out UTI

• Positive test does not confirm UTI

True/False: When testing the accuracy of microscopic detection of bacteriuria in dogs, air-dried and stained bacterial cultures have higher sensitivity and specificity compared to wet mounts.

True

In male goats, cattle, sheep, swine and some camelids, the bulbourethral ducts empty into the urethra at the ischial arch. What forms here that makes retrograde catherization almost impossible?

A urethral recess

The urethral process of the male goat is a site where ________ _________ can block the urethra

Urinary calculi

How to position an animal for cystocentesis

• Position animal in either dorsal recumbency (pad back or use trough for comfort), lateral recumbency, or standing.

• To reduce the possibility of prior urination, have owner carry small dogs from car and have cats in a carrier for several hours prior to arrival at the clinic

• Equipment - 22 gauge 1-1/2” needle with a 5 ml syringe

• Soft massage to relax pet. Localize and stabilize bladder.

True/False: if a sample of urine is not obtained via cystocentesis on the first attempt, redirect the needle

False, change the needle before making another attempt and DO NOT REDIRECT as organs may be lacerated

What are some pros and cons to free catch collection method of urine?

– No trauma

– Frequent contaminants

– Not recommended when suspecting urinary tract infection

– Requires cooperation and timing! (Midstream preferred)

• Good to have device to hold cup

– Preferred when monitoring hematuria or suspect bladder neoplasia

Urinalysis - Physical examination

Color

• Influenced by concentration, blood, myoglobin, methemoglobin, medications, bacteria, white blood cells

Clarity

• Tubidity-indicates solid particles suspended in urine (e.g., crystals, cells, etc.)

Odors

• Ammoniac - urease producing bacteria, cystitis

• Putrid-severe bacterial infection

• Sulfurous - Proteus infection

• Sweet - ketones

Canine USG normal range

1.001 - 1.070

Adequate concentration - 1.025

Feline USG normal range

1.001 - 1.090

Adequate concentration - 1.035

Urinalysis - Glucose

– Glucosuria with hyperglycemia

• e.g. DM, stressed cats, postprandial, Ketamine

– Glucosuria without hyperglycemia-proximal tubular disease

• e.g. Fanconi, hypoxia, toxins, or reagent strip contam w/peroxide,bleach

– False neg. with ascorbic acid, tetracyclines

Urinalysis - Bilirubin

Degrades in presence of UV light

Canine low renal threshold

Feline high renal threshold

Urinalysis - Ketones

Volatile - evaporate quickly

False + in very pigmented or high USG/low pH

May accompany glucosuria

Urinalysis - Urobilinogen

Indicates bile duct is patent

Normal pH of urine

6-7.5

Effect of high protein diet on pH? Effect of plant diet on pH?

High protein diet lowers pH

Plant diet causes higher pH

What values on dipstick may be unreliable in animals?

USG, nitrite, leukocytes, urobilinogen

When do conversations about goals of care typically begin in veterinary medicine?

They often begin when the patient presents with a potentially life-threatening or life-limiting disease.

What role do goals-of-care conversations play throughout a pet’s illness?

They guide diagnostics, treatment, and interventions, and are revisited as needed during the illness.

What are two main barriers to frequent goals-of-care conversations in veterinary and human medicine?

Limited time and insufficient training.

What can be the consequence of not having goals-of-care conversations?

Unwanted interventions and decreased quality of life for the patient.

What communication protocols from human medicine help deliver bad news and guide goals-of-care conversations?

SPIKES, ABCDE, BREAKS, and Serious Illness Conversation Guidelines (SICG).

List the 5 common steps shared across communication protocols adapted for veterinary use.

1) Elicit owner’s understanding

2) Ask how much detail they want

3) Provide tailored information

4) Respond empathetically

5) Review care strategies and decisions.

Who adapted the SICG for veterinary medicine and why is it significant?

Katherine Goldberg; it includes prompts to identify care goals for seriously ill animals and improve client and veterinarian satisfaction.

How do checklists improve end-of-life conversations?

They reduce medical errors and ensure key elements are addressed, improving outcomes and satisfaction.

Why is self-care important for veterinary professionals during end-of-life conversations?

Engaging in serious conversations can be emotionally taxing; preserving mental and physical health supports long-term well-being and effectiveness in care.

What is Critical Incident Stress Management (CISM)?

A structured tool originally from disaster management, adapted to help veterinary professionals cope with traumatic events like euthanasia or treatment failure.

Who are the “first” and “second” victims in CISM terminology?

First victims: clients and their pets; second victims: veterinary professionals traumatized by adverse events.

What is the goal of Critical Incident Stress Management?

To restore mental and emotional health post-trauma and improve team cohesion, retention, and productivity.

What are the three steps of the CISM process?

Stress management, defusing, and debriefing through shared conversations with staff.

What factors influence how end-of-life conversations unfold in veterinary settings?

The veterinarian’s personality, experience, and communication skills.

What percentage of clients are emotionally affected by the death of their pet?

70%

What percentage of clients experience severe grief?

Up to 30%

What percentage of clients report guilt over euthanasia?

Approximately 50%

What contributes to client grief during pet loss?

Perception of professional support provided by the veterinarian.

How often are veterinarians present at a patient’s death compared to other health care professionals?

5 times more often.

What can help reduce stress, compassion fatigue, and burnout among veterinary staff?

Promoting self-care, work-life balance, collegial support, and a respectful practice culture.

What are common sources of discomfort for veterinarians in end-of-life discussions?

Lack of training, time constraints, practice culture, self-blame, feelings of failure, uncertainty, patient QOL concerns, emotional burden.

What are common reasons for client anxiety during end-of-life discussions?

Self-blame, anticipatory grief, impact on bond, uncertainty, emotional response, and pet's QOL

What are the general phases of grief?

Numbness → Searching/yearning → Disorganization/despair → Acceptance and integration

What do alumni surveys identify as the most important skills for veterinary practice success?

Communication skills and dealing with clients

What is a known gap in veterinary education regarding communication?

A skills gap between curriculum content and real-world communication needs.

What are the positive outcomes of skillfully conducted end-of-life discussions?

Validation of decisions, emotional support, improved satisfaction, better client retention.

What are potential negative outcomes of poor end-of-life communication?

Complicated grief, reduced client compliance, lower satisfaction, and increased litigation risk.

What are the core elements of end-of-life communication in veterinary medicine?

Delivering bad news, QOL assessment, euthanasia decision-making, discussing the euthanasia process, and grief support.

What model is used to structure end-of-life conversations in veterinary medicine?

The SPIKES model:

• Setting

• Perception

• Invitation

• Knowledge

• Empathy

• Summary

What is the literal meaning of the word “euthanasia”?

From Greek: “eu” = good, “thanatos” = death

What is a key premise of end-of-life animal care?

End-of-life animal care involves a series of events and discussions, each presenting communication challenges.

What are the key events and discussions involved in euthanasia?

Discuss options, discuss the euthanasia process, support during and after the procedure, and offer grief resources.

What are prominent risk factors associated with severe grief in clients?

Level of attachment, societal attitudes towards pet death, professional support from veterinary staff, and euthanasia.

What are some client expectations during end-of-life care?

Personalized treatment, respect, full medical explanation, kindness and attentive listening, and treating the pet as unique.

What role does the client play as the 'voice' of the animal/pet?

Share observations, concerns, and provide insight on quality-of-life.

What are common communication challenges in end-of-life care?

Discomfort with emotion, time constraints, guiding clients through difficult decision-making, non-medical euthanasia requests, and financial considerations.

What are some aspects of the veterinarian's experience with euthanasia?

Concerns about own emotions, personal level of distress, impact of client presence, unpredictability of client emotions, and repeated demand in practice.

What are the core communication skills needed by a veterinarian?

Non-verbal awareness, open-ended inquiry and reflection, and empathy.

What are nonverbal essentials for veterinarians?

Maximize time and privacy and set the stage.

What are examples of nonverbal cues that can effectively convey support?

Open posture, eye contact, and appropriate touch.

What tasks should a veterinarian perform during end-of-life discussions?

To review information, discuss quality-of-life issues, help clients shift perspective to quality-of-life, and validate difficulty in making the decision.

How can a veterinarian address grief?

Reminisce about the pet, provide grief education/pet loss resources, provide follow-up, and convey messages of validation.

What are some strategies for addressing grief in children?

Avoid euphemisms, include children in decision-making when appropriate, provide healthy modeling, and help children express emotions.

Proestrus

begins with first appearance of blood-tinged vaginal discharge and ends with first acceptance of mating

Estrus

period that bitch allows mating

Diestrus

two months following estrus (reproductive tract under influence P4 from corpora lutea)

P4

Collect plain red top not gel barrier tube

Time to breed and timing of parturition

Rise in P4 > 2.0 ng/mL (and P4 continues to rise), breed on days 3, 4, 5, 6 post surge

Due date predicted as day 65 ± 1 day following the pre-ovulatory serum progesterone rise/LH peak

Value of also running vaginal cytology (cornification)

Neonatal care

Suction, gently swing downward

Mucous trap

Doxapram sublingual

“Not so gentle” rubbing

Tube feeding: red rubber catheter (nose to last rib)

Cats dystocia reported incidence

3.3-5.8%

Dystocia is higher in what types of cats?

Higher in purebred cats

Stage 1 of labor

Onset of uterine contractions

Clinical signs: pant, pace, nesting

Stage 2 of labor

Delivery of fetus

Stage 3 of labor

Delivery of membranes

Clinical signs of dystocia

Female vocalizing

Dam showing signs of pain

Licking at vulva during contraction