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I am treating a diabetic dog that was diagnosed 2 years ago. She is an 11 year old spayed female labrador mix. My associate did a glucose curve on her 3 months ago-Her glucose started at 400 and went down to 300 after 8 hours and had started back up by 9 hours. He increased her Novolin-N dose slightly to 0.9 units/kg.
Yesterday she presented for lethargy and anorexia. The owner is elderly and can't tell me a lot about her drinking and urinating. Her muscles were trembling and jerking and she was quite lethargic. Her glucose was >700. That was as high as my Abaxis machine would read. I double checked the glucose with my AlphaTrac glucose meter and it read "HI". Other abnormal chemistry results were BUN 79(7-25), Creat 2.4(0.3-1.4), Phos 8.6(2.9-6.6), CA 12.1 (8.6-11.8), ALP 265(20-150). Her PCV was 40. She had received her insulin the previous evening but nothing that morning. At 10am I gave her 25 units Novolin-N. At 1:30PM her glucose was 490 and at 4:30PM it was back up to 700. She had not had anything to eat all day. Owner finances were a concern and the owner didn't want the dog to stay at the hospital over night so we gave her SQ lactated ringers during the day instead of starting an IV. The dog went home at 5Pm with instructions to give 25 units of insulin in the evening.
Today she returned and was more alert and not showing any muscle jerking. She had still not eaten anything. At 11pm the previous evening the owner gave her 25 units Novolin-N, but she had not received any insulin this morning. This morning at 9am her glucose measures 95 on my AlphaTrac meter. At noon her glucose was 88 I did not give her any insulin today.
We were finally able to get a urine sample today(free catch). The glucose was 4+, ketones were negative, urine sediment shows 1+ WBC and 4+ rods.
Would a urinary tract infection make this dog's glucose levels bounce around like this? The ALP is a little high so Cushings could be a consideration I guess. The calcium is elevated but I am not detecting any lymph node enlargement or tumors other than lipomas. I am thinking since she didn't have any ketones in her urine that her glucose had not been high for very long-would this be safe to assume?
What am I missing?
Thanks, br/ DVM | How well is this owner able to give the insulin? | How much does stretch weigh? |
I am treating a diabetic dog that was diagnosed 2 years ago. She is an 11 year old spayed female labrador mix. My associate did a glucose curve on her 3 months ago-Her glucose started at 400 and went down to 300 after 8 hours and had started back up by 9 hours. He increased her Novolin-N dose slightly to 0.9 units/kg.
Yesterday she presented for lethargy and anorexia. The owner is elderly and can't tell me a lot about her drinking and urinating. Her muscles were trembling and jerking and she was quite lethargic. Her glucose was >700. That was as high as my Abaxis machine would read. I double checked the glucose with my AlphaTrac glucose meter and it read "HI". Other abnormal chemistry results were BUN 79(7-25), Creat 2.4(0.3-1.4), Phos 8.6(2.9-6.6), CA 12.1 (8.6-11.8), ALP 265(20-150). Her PCV was 40. She had received her insulin the previous evening but nothing that morning. At 10am I gave her 25 units Novolin-N. At 1:30PM her glucose was 490 and at 4:30PM it was back up to 700. She had not had anything to eat all day. Owner finances were a concern and the owner didn't want the dog to stay at the hospital over night so we gave her SQ lactated ringers during the day instead of starting an IV. The dog went home at 5Pm with instructions to give 25 units of insulin in the evening.
Today she returned and was more alert and not showing any muscle jerking. She had still not eaten anything. At 11pm the previous evening the owner gave her 25 units Novolin-N, but she had not received any insulin this morning. This morning at 9am her glucose measures 95 on my AlphaTrac meter. At noon her glucose was 88 I did not give her any insulin today.
We were finally able to get a urine sample today(free catch). The glucose was 4+, ketones were negative, urine sediment shows 1+ WBC and 4+ rods.
Would a urinary tract infection make this dog's glucose levels bounce around like this? The ALP is a little high so Cushings could be a consideration I guess. The calcium is elevated but I am not detecting any lymph node enlargement or tumors other than lipomas. I am thinking since she didn't have any ketones in her urine that her glucose had not been high for very long-would this be safe to assume?
What am I missing?
Thanks, br/ DVM | Can that be part of the problem? | How about her heart rate and body temp now? |
I am treating a diabetic dog that was diagnosed 2 years ago. She is an 11 year old spayed female labrador mix. My associate did a glucose curve on her 3 months ago-Her glucose started at 400 and went down to 300 after 8 hours and had started back up by 9 hours. He increased her Novolin-N dose slightly to 0.9 units/kg.
Yesterday she presented for lethargy and anorexia. The owner is elderly and can't tell me a lot about her drinking and urinating. Her muscles were trembling and jerking and she was quite lethargic. Her glucose was >700. That was as high as my Abaxis machine would read. I double checked the glucose with my AlphaTrac glucose meter and it read "HI". Other abnormal chemistry results were BUN 79(7-25), Creat 2.4(0.3-1.4), Phos 8.6(2.9-6.6), CA 12.1 (8.6-11.8), ALP 265(20-150). Her PCV was 40. She had received her insulin the previous evening but nothing that morning. At 10am I gave her 25 units Novolin-N. At 1:30PM her glucose was 490 and at 4:30PM it was back up to 700. She had not had anything to eat all day. Owner finances were a concern and the owner didn't want the dog to stay at the hospital over night so we gave her SQ lactated ringers during the day instead of starting an IV. The dog went home at 5Pm with instructions to give 25 units of insulin in the evening.
Today she returned and was more alert and not showing any muscle jerking. She had still not eaten anything. At 11pm the previous evening the owner gave her 25 units Novolin-N, but she had not received any insulin this morning. This morning at 9am her glucose measures 95 on my AlphaTrac meter. At noon her glucose was 88 I did not give her any insulin today.
We were finally able to get a urine sample today(free catch). The glucose was 4+, ketones were negative, urine sediment shows 1+ WBC and 4+ rods.
Would a urinary tract infection make this dog's glucose levels bounce around like this? The ALP is a little high so Cushings could be a consideration I guess. The calcium is elevated but I am not detecting any lymph node enlargement or tumors other than lipomas. I am thinking since she didn't have any ketones in her urine that her glucose had not been high for very long-would this be safe to assume?
What am I missing?
Thanks, br/ DVM | Does the dog have any clinical signs that are seen with cushing's but not diabetes? | Is he eating the canned version of a high protein/low carb diet? |
I am treating a diabetic dog that was diagnosed 2 years ago. She is an 11 year old spayed female labrador mix. My associate did a glucose curve on her 3 months ago-Her glucose started at 400 and went down to 300 after 8 hours and had started back up by 9 hours. He increased her Novolin-N dose slightly to 0.9 units/kg.
Yesterday she presented for lethargy and anorexia. The owner is elderly and can't tell me a lot about her drinking and urinating. Her muscles were trembling and jerking and she was quite lethargic. Her glucose was >700. That was as high as my Abaxis machine would read. I double checked the glucose with my AlphaTrac glucose meter and it read "HI". Other abnormal chemistry results were BUN 79(7-25), Creat 2.4(0.3-1.4), Phos 8.6(2.9-6.6), CA 12.1 (8.6-11.8), ALP 265(20-150). Her PCV was 40. She had received her insulin the previous evening but nothing that morning. At 10am I gave her 25 units Novolin-N. At 1:30PM her glucose was 490 and at 4:30PM it was back up to 700. She had not had anything to eat all day. Owner finances were a concern and the owner didn't want the dog to stay at the hospital over night so we gave her SQ lactated ringers during the day instead of starting an IV. The dog went home at 5Pm with instructions to give 25 units of insulin in the evening.
Today she returned and was more alert and not showing any muscle jerking. She had still not eaten anything. At 11pm the previous evening the owner gave her 25 units Novolin-N, but she had not received any insulin this morning. This morning at 9am her glucose measures 95 on my AlphaTrac meter. At noon her glucose was 88 I did not give her any insulin today.
We were finally able to get a urine sample today(free catch). The glucose was 4+, ketones were negative, urine sediment shows 1+ WBC and 4+ rods.
Would a urinary tract infection make this dog's glucose levels bounce around like this? The ALP is a little high so Cushings could be a consideration I guess. The calcium is elevated but I am not detecting any lymph node enlargement or tumors other than lipomas. I am thinking since she didn't have any ketones in her urine that her glucose had not been high for very long-would this be safe to assume?
What am I missing?
Thanks, br/ DVM | Did you do a rectal and palpate the anal sacs and nodes there? | Is he on pain meds? |
Hello,
Along with an internal medicine specialist and veterinary oncologist, I'm helping the management of a senior, MN, approx 20 lbc, Welsh Terrier having Transitional Cell Carcinoma, which has been relatively well managed over the past 12+ months with chemo, Chinese med whole food based cooling/neutral diet, nutraceuticals, acupuncture, and some Chinese herbs (Yunnan Biayao 1 cap every 12 hrs when there is bleeding).
As of the past few weeks, his tumor seems to be worsening. Determining exactly how big/invasive the tumor is as of late is very challenging, as even via ultrasound/other imaging it's not overtly clear.
He has been showing worsening clots (larger, more frequent) and more stranguria to the point that he is now hospitalized and on IVF. We are wondering the following about his Yunnan Biayao (YB).
1. If he is having a worsening in his clotting situation, should we consider giving less or discontinuing his YB?
2. Is there an alternative to YB that could potentially help with his condition?
From a Chinese medicine perspective, I feel he has blood stagnation, Qi stagnation, phlegm, and heat-toxin accumulation. He also has some mild degenerative changes in the facts of his T-L spine, so I feel he has Kidney Yang Deficiency.
Thank you,
☼ | Maybe consider switching to yunnan hong yao? | What brand is it? |
I'll keep this short because it is more of an "in general" question rather than go into a ton a specifics
We did a lateral condylar repair on a 10 yeardog following a fracture. My associate and I performed the procedure. It took almost 2 hours. This was last Thursday. We did a screw through the condyles and circlage wire around the top of the fracture. Postnop x-rays looked good. The owners reported evything was fine until last night. The dog did walk up the stairs yesterday and was using it. Last night the patient whined a lot and this morning, there was a repair failure.
Seeing as this was "probably" an inexperienced surgical error, or a problem with post op walking, etc, I don't know what to charge here. Oh and the client didn't pay for the whole surgery. Somehow, (I don't want to get started) the owner ended up paying only 1/4 of the . She knew the and assumed we hadn't had the charges finished. This obviously need a referral now. I'm not really in the position to eat the charges especially since the client was aware of the risks and that we hadn't done this surgery before. We offered referral but it was declined and the owner elected for us to do the surgery.
What would you do in this case regarding the outstanding? It would be leaving around $1600 on the table, | How is this an "inexperienced surgical error"? | Absolutely sure that he's on no exogenous steroids, including topicals on eyes, ears or skin? |
I'll keep this short because it is more of an "in general" question rather than go into a ton a specifics
We did a lateral condylar repair on a 10 yeardog following a fracture. My associate and I performed the procedure. It took almost 2 hours. This was last Thursday. We did a screw through the condyles and circlage wire around the top of the fracture. Postnop x-rays looked good. The owners reported evything was fine until last night. The dog did walk up the stairs yesterday and was using it. Last night the patient whined a lot and this morning, there was a repair failure.
Seeing as this was "probably" an inexperienced surgical error, or a problem with post op walking, etc, I don't know what to charge here. Oh and the client didn't pay for the whole surgery. Somehow, (I don't want to get started) the owner ended up paying only 1/4 of the . She knew the and assumed we hadn't had the charges finished. This obviously need a referral now. I'm not really in the position to eat the charges especially since the client was aware of the risks and that we hadn't done this surgery before. We offered referral but it was declined and the owner elected for us to do the surgery.
What would you do in this case regarding the outstanding? It would be leaving around $1600 on the table, | Would you be waling up/down stairs three days after surgery? | Potassium levels at this time? |
This is such a long his. I am not certain what may be relevant, so I am condensing as best I can.
Bandit is a DSH 14yo mn. 17#11oz In his his prior to being my patient, he was dx'd DM & put on W/D & PZI. He has also had pancreatitis, with v/d/pain, hospitaliztion, fluid therapy.
I began seeing Bandit in 2009. He was very well regulated according to curves, fructosamines. He was being monitored by a local internist. PZI 1-2 units BID. w/d food.
He is an indoor kitty with 3 other cats in household. In 2010, he came back FIV+. This confirmed Western Blot +.
He has had several FORL's develop over time, and has had many extractions.
May 2012 is where my s begins. He was given a new bag of W/D, and suddenly developed diarrhea. I saw clostridium and rod overgrowth in direct, possible giardia cysts. nothing else. Tx'd with panacur, flagyl, probiotic, new w/d. The diarrhea persisted for 2-3 weeks, no response to tx.
Ran a GI panel end of May:
Cobal low 168
Folate high 23.8
PLI high 4.7 Started Cobal inj's, switched to DM. Diarrhea resolved. Repeated in house PLI & was normal.
Pet did well until early September 2012. Now is PU/PD painful on T-L palp. BGs high, fructosamine high 434. Spondylosis of T12-T13-L1 noted on rads. Other BW normal. Started cosequin and a 3 day course of onsior. He improved, but continued with PU/PD. His insulin needs were now 4-5 units BID, and we were having dysregulation. We were also now having to compound insulin.
End of September he presented with pain, lethargy, inappetance, weakness and down in hocks. He was also licking his sides and pulling hair. PLI was abnormal and his BGs were still high. Treated him with fluids, cerenia, pain meds.
Continued with o checking BGs at home. BGs still running in the 200-300 range consistently.
Started on Gabapentin and Methylcobalamin orally. He continued being PU/PD, pulling hair out, but the weakness/down in hocks improved.
In November, we got Prozinc again, and finally got him regulated on 3u BID. His sugars have since been 85-195 consistently. But he is still PU/PD, still pulling out fur. In Dec, his BUN was 42 & Cr 2 (classically under 30 & 1.5-1.9), so I did a week of SQF. He had more dental disease, so we did dentistry 1-31, and removed several teeth with FORL's.
Since November, His BGs have been great. He is still PU/PD, PP, pulling out hair. He has never had allergies. He does not have fleas. There are no areas of alopecia or lesions. He maintains weight. Just wants to eat & drink constantly. His lab work is normal. I ran a free T4 today--is 27 (wnl).
He does not appear painful. Loves having his coat brushed. (Even the areas he is pulling on). He is ambulating well. His vitals are normal. Mouth healed well post extractions. He doesn't jump up as high or as much, but we know he has spondylosis. His coat is unkempt--he doesn't groom as much, but o brushes him daily. He occas vomits water or water and hair. Sometimes lays in strange spots and stretches out in strange ways, per o. She thinks he does this when his belly is upset.
Bandit is a wonderful cat, wonderful owner. He is no longer on cobalamin or gabapentin. (BTW, O didn't think gaba was helping) Eating DM wet and W/D wet and W/D dry.
What else can I do? What am I missing? Other ddx for hair pulling and PU/PD not showing up on lab work? Thank you for your help. This his is so long....
☼ | How much does the cat weigh now? | How long since the last urine culture? |
This is such a long his. I am not certain what may be relevant, so I am condensing as best I can.
Bandit is a DSH 14yo mn. 17#11oz In his his prior to being my patient, he was dx'd DM & put on W/D & PZI. He has also had pancreatitis, with v/d/pain, hospitaliztion, fluid therapy.
I began seeing Bandit in 2009. He was very well regulated according to curves, fructosamines. He was being monitored by a local internist. PZI 1-2 units BID. w/d food.
He is an indoor kitty with 3 other cats in household. In 2010, he came back FIV+. This confirmed Western Blot +.
He has had several FORL's develop over time, and has had many extractions.
May 2012 is where my s begins. He was given a new bag of W/D, and suddenly developed diarrhea. I saw clostridium and rod overgrowth in direct, possible giardia cysts. nothing else. Tx'd with panacur, flagyl, probiotic, new w/d. The diarrhea persisted for 2-3 weeks, no response to tx.
Ran a GI panel end of May:
Cobal low 168
Folate high 23.8
PLI high 4.7 Started Cobal inj's, switched to DM. Diarrhea resolved. Repeated in house PLI & was normal.
Pet did well until early September 2012. Now is PU/PD painful on T-L palp. BGs high, fructosamine high 434. Spondylosis of T12-T13-L1 noted on rads. Other BW normal. Started cosequin and a 3 day course of onsior. He improved, but continued with PU/PD. His insulin needs were now 4-5 units BID, and we were having dysregulation. We were also now having to compound insulin.
End of September he presented with pain, lethargy, inappetance, weakness and down in hocks. He was also licking his sides and pulling hair. PLI was abnormal and his BGs were still high. Treated him with fluids, cerenia, pain meds.
Continued with o checking BGs at home. BGs still running in the 200-300 range consistently.
Started on Gabapentin and Methylcobalamin orally. He continued being PU/PD, pulling hair out, but the weakness/down in hocks improved.
In November, we got Prozinc again, and finally got him regulated on 3u BID. His sugars have since been 85-195 consistently. But he is still PU/PD, still pulling out fur. In Dec, his BUN was 42 & Cr 2 (classically under 30 & 1.5-1.9), so I did a week of SQF. He had more dental disease, so we did dentistry 1-31, and removed several teeth with FORL's.
Since November, His BGs have been great. He is still PU/PD, PP, pulling out hair. He has never had allergies. He does not have fleas. There are no areas of alopecia or lesions. He maintains weight. Just wants to eat & drink constantly. His lab work is normal. I ran a free T4 today--is 27 (wnl).
He does not appear painful. Loves having his coat brushed. (Even the areas he is pulling on). He is ambulating well. His vitals are normal. Mouth healed well post extractions. He doesn't jump up as high or as much, but we know he has spondylosis. His coat is unkempt--he doesn't groom as much, but o brushes him daily. He occas vomits water or water and hair. Sometimes lays in strange spots and stretches out in strange ways, per o. She thinks he does this when his belly is upset.
Bandit is a wonderful cat, wonderful owner. He is no longer on cobalamin or gabapentin. (BTW, O didn't think gaba was helping) Eating DM wet and W/D wet and W/D dry.
What else can I do? What am I missing? Other ddx for hair pulling and PU/PD not showing up on lab work? Thank you for your help. This his is so long....
☼ | How is his body condition score? | What should she weigh? |
This is such a long his. I am not certain what may be relevant, so I am condensing as best I can.
Bandit is a DSH 14yo mn. 17#11oz In his his prior to being my patient, he was dx'd DM & put on W/D & PZI. He has also had pancreatitis, with v/d/pain, hospitaliztion, fluid therapy.
I began seeing Bandit in 2009. He was very well regulated according to curves, fructosamines. He was being monitored by a local internist. PZI 1-2 units BID. w/d food.
He is an indoor kitty with 3 other cats in household. In 2010, he came back FIV+. This confirmed Western Blot +.
He has had several FORL's develop over time, and has had many extractions.
May 2012 is where my s begins. He was given a new bag of W/D, and suddenly developed diarrhea. I saw clostridium and rod overgrowth in direct, possible giardia cysts. nothing else. Tx'd with panacur, flagyl, probiotic, new w/d. The diarrhea persisted for 2-3 weeks, no response to tx.
Ran a GI panel end of May:
Cobal low 168
Folate high 23.8
PLI high 4.7 Started Cobal inj's, switched to DM. Diarrhea resolved. Repeated in house PLI & was normal.
Pet did well until early September 2012. Now is PU/PD painful on T-L palp. BGs high, fructosamine high 434. Spondylosis of T12-T13-L1 noted on rads. Other BW normal. Started cosequin and a 3 day course of onsior. He improved, but continued with PU/PD. His insulin needs were now 4-5 units BID, and we were having dysregulation. We were also now having to compound insulin.
End of September he presented with pain, lethargy, inappetance, weakness and down in hocks. He was also licking his sides and pulling hair. PLI was abnormal and his BGs were still high. Treated him with fluids, cerenia, pain meds.
Continued with o checking BGs at home. BGs still running in the 200-300 range consistently.
Started on Gabapentin and Methylcobalamin orally. He continued being PU/PD, pulling hair out, but the weakness/down in hocks improved.
In November, we got Prozinc again, and finally got him regulated on 3u BID. His sugars have since been 85-195 consistently. But he is still PU/PD, still pulling out fur. In Dec, his BUN was 42 & Cr 2 (classically under 30 & 1.5-1.9), so I did a week of SQF. He had more dental disease, so we did dentistry 1-31, and removed several teeth with FORL's.
Since November, His BGs have been great. He is still PU/PD, PP, pulling out hair. He has never had allergies. He does not have fleas. There are no areas of alopecia or lesions. He maintains weight. Just wants to eat & drink constantly. His lab work is normal. I ran a free T4 today--is 27 (wnl).
He does not appear painful. Loves having his coat brushed. (Even the areas he is pulling on). He is ambulating well. His vitals are normal. Mouth healed well post extractions. He doesn't jump up as high or as much, but we know he has spondylosis. His coat is unkempt--he doesn't groom as much, but o brushes him daily. He occas vomits water or water and hair. Sometimes lays in strange spots and stretches out in strange ways, per o. She thinks he does this when his belly is upset.
Bandit is a wonderful cat, wonderful owner. He is no longer on cobalamin or gabapentin. (BTW, O didn't think gaba was helping) Eating DM wet and W/D wet and W/D dry.
What else can I do? What am I missing? Other ddx for hair pulling and PU/PD not showing up on lab work? Thank you for your help. This his is so long....
☼ | It would be a good idea to try to rule out a uti/pyelonephritis as the cause of the pu/pd in this diabetic cat; have a urinalysis and urine culture (even if sediment is unremarkable) been run in this cat yet? | As far as the agnosis of lymphoma, do you have histopath? |
This is such a long his. I am not certain what may be relevant, so I am condensing as best I can.
Bandit is a DSH 14yo mn. 17#11oz In his his prior to being my patient, he was dx'd DM & put on W/D & PZI. He has also had pancreatitis, with v/d/pain, hospitaliztion, fluid therapy.
I began seeing Bandit in 2009. He was very well regulated according to curves, fructosamines. He was being monitored by a local internist. PZI 1-2 units BID. w/d food.
He is an indoor kitty with 3 other cats in household. In 2010, he came back FIV+. This confirmed Western Blot +.
He has had several FORL's develop over time, and has had many extractions.
May 2012 is where my s begins. He was given a new bag of W/D, and suddenly developed diarrhea. I saw clostridium and rod overgrowth in direct, possible giardia cysts. nothing else. Tx'd with panacur, flagyl, probiotic, new w/d. The diarrhea persisted for 2-3 weeks, no response to tx.
Ran a GI panel end of May:
Cobal low 168
Folate high 23.8
PLI high 4.7 Started Cobal inj's, switched to DM. Diarrhea resolved. Repeated in house PLI & was normal.
Pet did well until early September 2012. Now is PU/PD painful on T-L palp. BGs high, fructosamine high 434. Spondylosis of T12-T13-L1 noted on rads. Other BW normal. Started cosequin and a 3 day course of onsior. He improved, but continued with PU/PD. His insulin needs were now 4-5 units BID, and we were having dysregulation. We were also now having to compound insulin.
End of September he presented with pain, lethargy, inappetance, weakness and down in hocks. He was also licking his sides and pulling hair. PLI was abnormal and his BGs were still high. Treated him with fluids, cerenia, pain meds.
Continued with o checking BGs at home. BGs still running in the 200-300 range consistently.
Started on Gabapentin and Methylcobalamin orally. He continued being PU/PD, pulling hair out, but the weakness/down in hocks improved.
In November, we got Prozinc again, and finally got him regulated on 3u BID. His sugars have since been 85-195 consistently. But he is still PU/PD, still pulling out fur. In Dec, his BUN was 42 & Cr 2 (classically under 30 & 1.5-1.9), so I did a week of SQF. He had more dental disease, so we did dentistry 1-31, and removed several teeth with FORL's.
Since November, His BGs have been great. He is still PU/PD, PP, pulling out hair. He has never had allergies. He does not have fleas. There are no areas of alopecia or lesions. He maintains weight. Just wants to eat & drink constantly. His lab work is normal. I ran a free T4 today--is 27 (wnl).
He does not appear painful. Loves having his coat brushed. (Even the areas he is pulling on). He is ambulating well. His vitals are normal. Mouth healed well post extractions. He doesn't jump up as high or as much, but we know he has spondylosis. His coat is unkempt--he doesn't groom as much, but o brushes him daily. He occas vomits water or water and hair. Sometimes lays in strange spots and stretches out in strange ways, per o. She thinks he does this when his belly is upset.
Bandit is a wonderful cat, wonderful owner. He is no longer on cobalamin or gabapentin. (BTW, O didn't think gaba was helping) Eating DM wet and W/D wet and W/D dry.
What else can I do? What am I missing? Other ddx for hair pulling and PU/PD not showing up on lab work? Thank you for your help. This his is so long....
☼ | If so, how's his usg? | Did you have any pictures? |
This is such a long his. I am not certain what may be relevant, so I am condensing as best I can.
Bandit is a DSH 14yo mn. 17#11oz In his his prior to being my patient, he was dx'd DM & put on W/D & PZI. He has also had pancreatitis, with v/d/pain, hospitaliztion, fluid therapy.
I began seeing Bandit in 2009. He was very well regulated according to curves, fructosamines. He was being monitored by a local internist. PZI 1-2 units BID. w/d food.
He is an indoor kitty with 3 other cats in household. In 2010, he came back FIV+. This confirmed Western Blot +.
He has had several FORL's develop over time, and has had many extractions.
May 2012 is where my s begins. He was given a new bag of W/D, and suddenly developed diarrhea. I saw clostridium and rod overgrowth in direct, possible giardia cysts. nothing else. Tx'd with panacur, flagyl, probiotic, new w/d. The diarrhea persisted for 2-3 weeks, no response to tx.
Ran a GI panel end of May:
Cobal low 168
Folate high 23.8
PLI high 4.7 Started Cobal inj's, switched to DM. Diarrhea resolved. Repeated in house PLI & was normal.
Pet did well until early September 2012. Now is PU/PD painful on T-L palp. BGs high, fructosamine high 434. Spondylosis of T12-T13-L1 noted on rads. Other BW normal. Started cosequin and a 3 day course of onsior. He improved, but continued with PU/PD. His insulin needs were now 4-5 units BID, and we were having dysregulation. We were also now having to compound insulin.
End of September he presented with pain, lethargy, inappetance, weakness and down in hocks. He was also licking his sides and pulling hair. PLI was abnormal and his BGs were still high. Treated him with fluids, cerenia, pain meds.
Continued with o checking BGs at home. BGs still running in the 200-300 range consistently.
Started on Gabapentin and Methylcobalamin orally. He continued being PU/PD, pulling hair out, but the weakness/down in hocks improved.
In November, we got Prozinc again, and finally got him regulated on 3u BID. His sugars have since been 85-195 consistently. But he is still PU/PD, still pulling out fur. In Dec, his BUN was 42 & Cr 2 (classically under 30 & 1.5-1.9), so I did a week of SQF. He had more dental disease, so we did dentistry 1-31, and removed several teeth with FORL's.
Since November, His BGs have been great. He is still PU/PD, PP, pulling out hair. He has never had allergies. He does not have fleas. There are no areas of alopecia or lesions. He maintains weight. Just wants to eat & drink constantly. His lab work is normal. I ran a free T4 today--is 27 (wnl).
He does not appear painful. Loves having his coat brushed. (Even the areas he is pulling on). He is ambulating well. His vitals are normal. Mouth healed well post extractions. He doesn't jump up as high or as much, but we know he has spondylosis. His coat is unkempt--he doesn't groom as much, but o brushes him daily. He occas vomits water or water and hair. Sometimes lays in strange spots and stretches out in strange ways, per o. She thinks he does this when his belly is upset.
Bandit is a wonderful cat, wonderful owner. He is no longer on cobalamin or gabapentin. (BTW, O didn't think gaba was helping) Eating DM wet and W/D wet and W/D dry.
What else can I do? What am I missing? Other ddx for hair pulling and PU/PD not showing up on lab work? Thank you for your help. This his is so long....
☼ | How has his weight been trending and his bcs? | Given his small stature, neuro signs/hypersalivation and the increased alt - can you post up all of his labs? |
This is such a long his. I am not certain what may be relevant, so I am condensing as best I can.
Bandit is a DSH 14yo mn. 17#11oz In his his prior to being my patient, he was dx'd DM & put on W/D & PZI. He has also had pancreatitis, with v/d/pain, hospitaliztion, fluid therapy.
I began seeing Bandit in 2009. He was very well regulated according to curves, fructosamines. He was being monitored by a local internist. PZI 1-2 units BID. w/d food.
He is an indoor kitty with 3 other cats in household. In 2010, he came back FIV+. This confirmed Western Blot +.
He has had several FORL's develop over time, and has had many extractions.
May 2012 is where my s begins. He was given a new bag of W/D, and suddenly developed diarrhea. I saw clostridium and rod overgrowth in direct, possible giardia cysts. nothing else. Tx'd with panacur, flagyl, probiotic, new w/d. The diarrhea persisted for 2-3 weeks, no response to tx.
Ran a GI panel end of May:
Cobal low 168
Folate high 23.8
PLI high 4.7 Started Cobal inj's, switched to DM. Diarrhea resolved. Repeated in house PLI & was normal.
Pet did well until early September 2012. Now is PU/PD painful on T-L palp. BGs high, fructosamine high 434. Spondylosis of T12-T13-L1 noted on rads. Other BW normal. Started cosequin and a 3 day course of onsior. He improved, but continued with PU/PD. His insulin needs were now 4-5 units BID, and we were having dysregulation. We were also now having to compound insulin.
End of September he presented with pain, lethargy, inappetance, weakness and down in hocks. He was also licking his sides and pulling hair. PLI was abnormal and his BGs were still high. Treated him with fluids, cerenia, pain meds.
Continued with o checking BGs at home. BGs still running in the 200-300 range consistently.
Started on Gabapentin and Methylcobalamin orally. He continued being PU/PD, pulling hair out, but the weakness/down in hocks improved.
In November, we got Prozinc again, and finally got him regulated on 3u BID. His sugars have since been 85-195 consistently. But he is still PU/PD, still pulling out fur. In Dec, his BUN was 42 & Cr 2 (classically under 30 & 1.5-1.9), so I did a week of SQF. He had more dental disease, so we did dentistry 1-31, and removed several teeth with FORL's.
Since November, His BGs have been great. He is still PU/PD, PP, pulling out hair. He has never had allergies. He does not have fleas. There are no areas of alopecia or lesions. He maintains weight. Just wants to eat & drink constantly. His lab work is normal. I ran a free T4 today--is 27 (wnl).
He does not appear painful. Loves having his coat brushed. (Even the areas he is pulling on). He is ambulating well. His vitals are normal. Mouth healed well post extractions. He doesn't jump up as high or as much, but we know he has spondylosis. His coat is unkempt--he doesn't groom as much, but o brushes him daily. He occas vomits water or water and hair. Sometimes lays in strange spots and stretches out in strange ways, per o. She thinks he does this when his belly is upset.
Bandit is a wonderful cat, wonderful owner. He is no longer on cobalamin or gabapentin. (BTW, O didn't think gaba was helping) Eating DM wet and W/D wet and W/D dry.
What else can I do? What am I missing? Other ddx for hair pulling and PU/PD not showing up on lab work? Thank you for your help. This his is so long....
☼ | Is he still 17 lb 11 oz? | Crusts? |
This is such a long his. I am not certain what may be relevant, so I am condensing as best I can.
Bandit is a DSH 14yo mn. 17#11oz In his his prior to being my patient, he was dx'd DM & put on W/D & PZI. He has also had pancreatitis, with v/d/pain, hospitaliztion, fluid therapy.
I began seeing Bandit in 2009. He was very well regulated according to curves, fructosamines. He was being monitored by a local internist. PZI 1-2 units BID. w/d food.
He is an indoor kitty with 3 other cats in household. In 2010, he came back FIV+. This confirmed Western Blot +.
He has had several FORL's develop over time, and has had many extractions.
May 2012 is where my s begins. He was given a new bag of W/D, and suddenly developed diarrhea. I saw clostridium and rod overgrowth in direct, possible giardia cysts. nothing else. Tx'd with panacur, flagyl, probiotic, new w/d. The diarrhea persisted for 2-3 weeks, no response to tx.
Ran a GI panel end of May:
Cobal low 168
Folate high 23.8
PLI high 4.7 Started Cobal inj's, switched to DM. Diarrhea resolved. Repeated in house PLI & was normal.
Pet did well until early September 2012. Now is PU/PD painful on T-L palp. BGs high, fructosamine high 434. Spondylosis of T12-T13-L1 noted on rads. Other BW normal. Started cosequin and a 3 day course of onsior. He improved, but continued with PU/PD. His insulin needs were now 4-5 units BID, and we were having dysregulation. We were also now having to compound insulin.
End of September he presented with pain, lethargy, inappetance, weakness and down in hocks. He was also licking his sides and pulling hair. PLI was abnormal and his BGs were still high. Treated him with fluids, cerenia, pain meds.
Continued with o checking BGs at home. BGs still running in the 200-300 range consistently.
Started on Gabapentin and Methylcobalamin orally. He continued being PU/PD, pulling hair out, but the weakness/down in hocks improved.
In November, we got Prozinc again, and finally got him regulated on 3u BID. His sugars have since been 85-195 consistently. But he is still PU/PD, still pulling out fur. In Dec, his BUN was 42 & Cr 2 (classically under 30 & 1.5-1.9), so I did a week of SQF. He had more dental disease, so we did dentistry 1-31, and removed several teeth with FORL's.
Since November, His BGs have been great. He is still PU/PD, PP, pulling out hair. He has never had allergies. He does not have fleas. There are no areas of alopecia or lesions. He maintains weight. Just wants to eat & drink constantly. His lab work is normal. I ran a free T4 today--is 27 (wnl).
He does not appear painful. Loves having his coat brushed. (Even the areas he is pulling on). He is ambulating well. His vitals are normal. Mouth healed well post extractions. He doesn't jump up as high or as much, but we know he has spondylosis. His coat is unkempt--he doesn't groom as much, but o brushes him daily. He occas vomits water or water and hair. Sometimes lays in strange spots and stretches out in strange ways, per o. She thinks he does this when his belly is upset.
Bandit is a wonderful cat, wonderful owner. He is no longer on cobalamin or gabapentin. (BTW, O didn't think gaba was helping) Eating DM wet and W/D wet and W/D dry.
What else can I do? What am I missing? Other ddx for hair pulling and PU/PD not showing up on lab work? Thank you for your help. This his is so long....
☼ | If he's been pulling out his hair, how is it that there's no alopecia? | Did you leave masses in? |
Hi, Just did some wellness labwork on a 2.5 year old FS Burmese cat. She is clinically well, very active. Although on exam I noticed she's athin/boney, and she has lost about 4 ounces in the past few months.
Chem BUN 32, Creat 2.6
Her bladder was empty so we were unable to get urine at the time. I have her back in today trying to get urine but her bladder is empty again.
The owner is upset with me, I'm not sure exactly why - probably because she's concerned there may be a problem. She really does not want to do the UA. She also seems to be upset because at this point I told her I need more information to know if there's a problem. I recommended the UA and rechecking BUN and Creatinine. The owner is already thinking of getting a second opinion (?!!!).
My question is - do we see increased creatinine in Burmese cats, with it being normal? I saw someone briefly mention this on a VIN post. I checked her pre-OVH labwork from when she was 7 months old and her creatinine was 1.9.
If her urine is well-concentrated and creatinine remains high, how worried should I be?
Also, any hints on how to make sure a cat comes in with an empty bladder? Lock up overnight in the bathroom with no litter box?
☼ | Was there any evidence of dehydration on exam? | Do you have any video of how he's walking? |
Hi, Just did some wellness labwork on a 2.5 year old FS Burmese cat. She is clinically well, very active. Although on exam I noticed she's athin/boney, and she has lost about 4 ounces in the past few months.
Chem BUN 32, Creat 2.6
Her bladder was empty so we were unable to get urine at the time. I have her back in today trying to get urine but her bladder is empty again.
The owner is upset with me, I'm not sure exactly why - probably because she's concerned there may be a problem. She really does not want to do the UA. She also seems to be upset because at this point I told her I need more information to know if there's a problem. I recommended the UA and rechecking BUN and Creatinine. The owner is already thinking of getting a second opinion (?!!!).
My question is - do we see increased creatinine in Burmese cats, with it being normal? I saw someone briefly mention this on a VIN post. I checked her pre-OVH labwork from when she was 7 months old and her creatinine was 1.9.
If her urine is well-concentrated and creatinine remains high, how worried should I be?
Also, any hints on how to make sure a cat comes in with an empty bladder? Lock up overnight in the bathroom with no litter box?
☼ | Were tp/pcv normal? | Treats? |
Hi, Just did some wellness labwork on a 2.5 year old FS Burmese cat. She is clinically well, very active. Although on exam I noticed she's athin/boney, and she has lost about 4 ounces in the past few months.
Chem BUN 32, Creat 2.6
Her bladder was empty so we were unable to get urine at the time. I have her back in today trying to get urine but her bladder is empty again.
The owner is upset with me, I'm not sure exactly why - probably because she's concerned there may be a problem. She really does not want to do the UA. She also seems to be upset because at this point I told her I need more information to know if there's a problem. I recommended the UA and rechecking BUN and Creatinine. The owner is already thinking of getting a second opinion (?!!!).
My question is - do we see increased creatinine in Burmese cats, with it being normal? I saw someone briefly mention this on a VIN post. I checked her pre-OVH labwork from when she was 7 months old and her creatinine was 1.9.
If her urine is well-concentrated and creatinine remains high, how worried should I be?
Also, any hints on how to make sure a cat comes in with an empty bladder? Lock up overnight in the bathroom with no litter box?
☼ | Potassium and phosphorus ok? | Did you also check bp and urine culture? |
I have a client who has requested information, dosing, for Cats claw herb for her ancient dog. I have never heard of this herb product. Can anyone help? Thanks in advance.
☼ | Confused? | (e.g. phenobarb, clomicalm, zonisamide, tms, aspirin or steroids (including topicals on eyes, ears or skin)? |
Hi there,
I recently took over a complicated case that I would appreciate some help with. This is a 9yo MN Shih Tzu with pruritus since ~3-4yo. When I saw him for the first time a couple of weeks ago he had m2 lichenified, hyperpigmented and alopecic skin on ventral neck, thorax and abdomen. Skin looked great on dorsum, around head and back end. Pruritus seems to be year-round. Has been on Atopica for 4-5 years which owner thinks initially worked very well but now doesn't work very well any more. On Revolution in the summer. Now he's developed severe gingival hyperplasia and periodontal disease (I assume from the Atopica), came in for bleeding from mouth, I extracted several teeth and decreased his Atopica dose to half. The oral bleeding resolved however I'm not sure what to do w/ his allergy/diet etc. His pruritus isn't any worse after decreasing dose of Atopica (although from the look of the skin I don't know how much it had been helping anyway). He has been on canned Z/D. Had Calcium Oxalate stones removed 3 years ago and that's why he's been on the canned food. Medication he's been on are Atopica, potassium citrate, hydroxyzine daily. Bloodwork is WNL. O has cost concerns and has declined referral.
My dilemma is: I don't want to switch from Atopica to prednisone because of possible increased calcium secretion in the urine. O is happy for me to suggest another food (KO soaked in warm water?) that may work better than Z/D. I'm at a loss here on what to do here, and would love some suggestions. Thanks in advance!
☼ | Thyroid normal too? | Was there anything else at all abnormal on the cbc/chem/ua? |
Hi there,
I recently took over a complicated case that I would appreciate some help with. This is a 9yo MN Shih Tzu with pruritus since ~3-4yo. When I saw him for the first time a couple of weeks ago he had m2 lichenified, hyperpigmented and alopecic skin on ventral neck, thorax and abdomen. Skin looked great on dorsum, around head and back end. Pruritus seems to be year-round. Has been on Atopica for 4-5 years which owner thinks initially worked very well but now doesn't work very well any more. On Revolution in the summer. Now he's developed severe gingival hyperplasia and periodontal disease (I assume from the Atopica), came in for bleeding from mouth, I extracted several teeth and decreased his Atopica dose to half. The oral bleeding resolved however I'm not sure what to do w/ his allergy/diet etc. His pruritus isn't any worse after decreasing dose of Atopica (although from the look of the skin I don't know how much it had been helping anyway). He has been on canned Z/D. Had Calcium Oxalate stones removed 3 years ago and that's why he's been on the canned food. Medication he's been on are Atopica, potassium citrate, hydroxyzine daily. Bloodwork is WNL. O has cost concerns and has declined referral.
My dilemma is: I don't want to switch from Atopica to prednisone because of possible increased calcium secretion in the urine. O is happy for me to suggest another food (KO soaked in warm water?) that may work better than Z/D. I'm at a loss here on what to do here, and would love some suggestions. Thanks in advance!
☼ | Was a skin scrape done for demodex? | Can you please post the entire thing? |
Hi there,
I recently took over a complicated case that I would appreciate some help with. This is a 9yo MN Shih Tzu with pruritus since ~3-4yo. When I saw him for the first time a couple of weeks ago he had m2 lichenified, hyperpigmented and alopecic skin on ventral neck, thorax and abdomen. Skin looked great on dorsum, around head and back end. Pruritus seems to be year-round. Has been on Atopica for 4-5 years which owner thinks initially worked very well but now doesn't work very well any more. On Revolution in the summer. Now he's developed severe gingival hyperplasia and periodontal disease (I assume from the Atopica), came in for bleeding from mouth, I extracted several teeth and decreased his Atopica dose to half. The oral bleeding resolved however I'm not sure what to do w/ his allergy/diet etc. His pruritus isn't any worse after decreasing dose of Atopica (although from the look of the skin I don't know how much it had been helping anyway). He has been on canned Z/D. Had Calcium Oxalate stones removed 3 years ago and that's why he's been on the canned food. Medication he's been on are Atopica, potassium citrate, hydroxyzine daily. Bloodwork is WNL. O has cost concerns and has declined referral.
My dilemma is: I don't want to switch from Atopica to prednisone because of possible increased calcium secretion in the urine. O is happy for me to suggest another food (KO soaked in warm water?) that may work better than Z/D. I'm at a loss here on what to do here, and would love some suggestions. Thanks in advance!
☼ | Cytology for malassezia? | If so have you ever tried giving insulin before the morning meal to "maybe" help blunt the post-prandial rise in the blood glucose concentrations? |
Hi there,
I recently took over a complicated case that I would appreciate some help with. This is a 9yo MN Shih Tzu with pruritus since ~3-4yo. When I saw him for the first time a couple of weeks ago he had m2 lichenified, hyperpigmented and alopecic skin on ventral neck, thorax and abdomen. Skin looked great on dorsum, around head and back end. Pruritus seems to be year-round. Has been on Atopica for 4-5 years which owner thinks initially worked very well but now doesn't work very well any more. On Revolution in the summer. Now he's developed severe gingival hyperplasia and periodontal disease (I assume from the Atopica), came in for bleeding from mouth, I extracted several teeth and decreased his Atopica dose to half. The oral bleeding resolved however I'm not sure what to do w/ his allergy/diet etc. His pruritus isn't any worse after decreasing dose of Atopica (although from the look of the skin I don't know how much it had been helping anyway). He has been on canned Z/D. Had Calcium Oxalate stones removed 3 years ago and that's why he's been on the canned food. Medication he's been on are Atopica, potassium citrate, hydroxyzine daily. Bloodwork is WNL. O has cost concerns and has declined referral.
My dilemma is: I don't want to switch from Atopica to prednisone because of possible increased calcium secretion in the urine. O is happy for me to suggest another food (KO soaked in warm water?) that may work better than Z/D. I'm at a loss here on what to do here, and would love some suggestions. Thanks in advance!
☼ | How was he treated at this visit? | Did you do the doxycycline for a full month for things like ehrlichia? |
Hi there,
I recently took over a complicated case that I would appreciate some help with. This is a 9yo MN Shih Tzu with pruritus since ~3-4yo. When I saw him for the first time a couple of weeks ago he had m2 lichenified, hyperpigmented and alopecic skin on ventral neck, thorax and abdomen. Skin looked great on dorsum, around head and back end. Pruritus seems to be year-round. Has been on Atopica for 4-5 years which owner thinks initially worked very well but now doesn't work very well any more. On Revolution in the summer. Now he's developed severe gingival hyperplasia and periodontal disease (I assume from the Atopica), came in for bleeding from mouth, I extracted several teeth and decreased his Atopica dose to half. The oral bleeding resolved however I'm not sure what to do w/ his allergy/diet etc. His pruritus isn't any worse after decreasing dose of Atopica (although from the look of the skin I don't know how much it had been helping anyway). He has been on canned Z/D. Had Calcium Oxalate stones removed 3 years ago and that's why he's been on the canned food. Medication he's been on are Atopica, potassium citrate, hydroxyzine daily. Bloodwork is WNL. O has cost concerns and has declined referral.
My dilemma is: I don't want to switch from Atopica to prednisone because of possible increased calcium secretion in the urine. O is happy for me to suggest another food (KO soaked in warm water?) that may work better than Z/D. I'm at a loss here on what to do here, and would love some suggestions. Thanks in advance!
☼ | Is the urine checked frequently? | It may be that she's developing cushing's---have you seen the urine s.g.? |
Hi,
I have a 9 year old MN DSH that is newly diagnosed hyperthyroid and diabetic. The diabetes was diagnosed in November, but owner was very limited financially. So we did not run a thyroid panel at the time. She did not want to use glargine insulin at the time.
2 months later, the owner had done veryfollow-up and had increased the cat up to 11 U BID of PZI...the cat had lost 4 lbs of body weight. at this follow-up she consented to full bloodwork panel, including a thyroid panel. so the hyperthyroidism is only recently being addressed. At this time, she wanted to switch to Novolin since PZI had increased in price. I told her that would be fine since we are going to be start at a very low insulin dose due to her poor compliance.
It has been 3 weeks since we started the methimazole and she came in for a recheck. we are at 8 U BID on Novolin but the cat is still PU/PD and losing weight. I don't want to increase the insulin more than 1 U per week. The cat is down to 17 lbs (from 21 lbs). The owner has a better job and more money to spend on her cat. She would be willing to purchase the Glargine at this time. Do you think it's work switching insulin again? Is glargine that much better than Novolin that you would postpone longer on achieving adequate blood glucose control?
Please let me know your opinion so that we can get this cat's diabetes under better control ASAP. Will know if hyperthyroidism is controlled on bloodwork sent out today.
Thanks.
☼ | Which pzi insulin is this? | Is it really incontinence or could it be pollakiuria? |
Hi,
I have a 9 year old MN DSH that is newly diagnosed hyperthyroid and diabetic. The diabetes was diagnosed in November, but owner was very limited financially. So we did not run a thyroid panel at the time. She did not want to use glargine insulin at the time.
2 months later, the owner had done veryfollow-up and had increased the cat up to 11 U BID of PZI...the cat had lost 4 lbs of body weight. at this follow-up she consented to full bloodwork panel, including a thyroid panel. so the hyperthyroidism is only recently being addressed. At this time, she wanted to switch to Novolin since PZI had increased in price. I told her that would be fine since we are going to be start at a very low insulin dose due to her poor compliance.
It has been 3 weeks since we started the methimazole and she came in for a recheck. we are at 8 U BID on Novolin but the cat is still PU/PD and losing weight. I don't want to increase the insulin more than 1 U per week. The cat is down to 17 lbs (from 21 lbs). The owner has a better job and more money to spend on her cat. She would be willing to purchase the Glargine at this time. Do you think it's work switching insulin again? Is glargine that much better than Novolin that you would postpone longer on achieving adequate blood glucose control?
Please let me know your opinion so that we can get this cat's diabetes under better control ASAP. Will know if hyperthyroidism is controlled on bloodwork sent out today.
Thanks.
☼ | Is it compounded? | What sort of self-mutilation and has a physical work up been done for this? |
Hi,
I have a 9 year old MN DSH that is newly diagnosed hyperthyroid and diabetic. The diabetes was diagnosed in November, but owner was very limited financially. So we did not run a thyroid panel at the time. She did not want to use glargine insulin at the time.
2 months later, the owner had done veryfollow-up and had increased the cat up to 11 U BID of PZI...the cat had lost 4 lbs of body weight. at this follow-up she consented to full bloodwork panel, including a thyroid panel. so the hyperthyroidism is only recently being addressed. At this time, she wanted to switch to Novolin since PZI had increased in price. I told her that would be fine since we are going to be start at a very low insulin dose due to her poor compliance.
It has been 3 weeks since we started the methimazole and she came in for a recheck. we are at 8 U BID on Novolin but the cat is still PU/PD and losing weight. I don't want to increase the insulin more than 1 U per week. The cat is down to 17 lbs (from 21 lbs). The owner has a better job and more money to spend on her cat. She would be willing to purchase the Glargine at this time. Do you think it's work switching insulin again? Is glargine that much better than Novolin that you would postpone longer on achieving adequate blood glucose control?
Please let me know your opinion so that we can get this cat's diabetes under better control ASAP. Will know if hyperthyroidism is controlled on bloodwork sent out today.
Thanks.
☼ | Which novolin? | Than butorphanol? |
Hi,
Am relatively new grad and DKA is my personal white whale. I had one as a student which we managed the way all the books say and she did well but it was very stressful to do the right way. Now I am in the real world where finances, lack of equipment etc make by the book way impossible. And it is really stressing me out. Am in my second job now and run into the same issues at both. What are the basic guidelines for monitoring, insulin administration (esp if only have things like humulin N, no reg insulin etc, no ability to set CRIs of insulin, no buretrols etc) in this situation? Realizing there is not perfect answer would just like a basic outline. We can run fluids but have no regular insulin to use, just Humulin N, and no istat just full chem rotors can run in house and glucometer, have urine strips, owners with some finances but not unlimited. Any thoughts, I realize each situation is going to be different just looking for some ideas from GPs who have done this with success. My current patient is going to emergency tonight (where they have all the bells and whistles) for initial stabilization which is great (she came in very late in the day) but I will take her over in the morning again so will be worrying and studying tonight for it but feel so helpless without all the tools we were taught to use. Any help much appreciated.
☼ | Have you actually asked your boss if you can get regular insulin? | What food is he currently on? |
Pumpkin is an almost 15 year old spayed female kitty who is overweight (16lbs) and was diagnosed as diabetic in 2008 at a previous clinic and was on Vetsulin until 2011, on which the owners felt she was well-regulated clinically (plantigrade stance and significant PU/PD resolved). In 2011 she was switched to PZI and owners saw clinical signs get worse. During that period I only found that fructosamines and spot BG checks were done, and all were always high.
She came to us for a second opinion at that time and we did a chem and CBC. All was normal other than BG at time of that draw was 55, so we ended up decreasing the PZI, getting her onto regular meal feeding on DM, and changed insulin injection site from scruff to flanks. Based on a curve 2 weeks later when she started with a BG of 42 pre-insulin to 241 peak, insulin was discontinued entirely, but was started again 2 weeks later and we tried to manage her on PZI over the next year, with owner doing curves at home. She never was very tightly regulated.
In May 2012 we switched her to glargine and she has been on 3 Units BID since then, despite at one point our recommendation to go up to 4 U based on a curve (the owners are very nervous about increasing the insulin so I think they decided not to).
Last urinalysis and chem panel were Jan 2013 and all was normal other than glucosuria, BUN was high at 44 (CREAT 1.3), and sodium and chloride each mildly low. Fructosamine was high. She was in for a curve shortly after that and started at BG of 250. The owner had not fed the cat that morning at 6:30 and given insulin, like normal, but brought it in with her. We gave 3 U and fed her at 8:00 and by 2pm the BG was 80, at 4pm it was 35. (In the meantime we've learned that we were using the wrong code for these measurements- we have an Alphatrak 1 and are using alphatrak 2 strips, so were supposed to use code 7 instead of what's on the bottle but did not-that causes falsely low values, but still it's too low).
This happened after the owner called at noon to remind us to do the noon feeding. I learned then that she'd been actually feeding 4 meals per day because she was worried about the BG falling too low. I recommended for better control only feeding BID, so did not feed that noon meal while in the clinic, but then over the course of the afternoon the BG dropped and we thought maybe it was Somogyi effect. So we decreased to 2 U Glargine BID and let her kept doing the 4 feedings, but rec that once we get her regulated we try to get her to 2 feedings. We did decrease the amount fed, hoping if we can get her to a healthy weight that will help us regulate.
However, she was back Monday and all readings hovered between approximately 300-320, when done with her normal 6:30 feeding and insulin, along with the 12pm feeding in clinic. She did lose .3 lbs on the decreased feeding, a step in the right directin, but now we increased her back to 3 units. What are we missing here? Owner feels clinical signs are well-controlled (other than she does have diabetic cataracts) but we just can't seem to get her into a normal range. | Canned or dry? | Is the timing for the am and pm insulin and food at 9 am and 9 pm? |
Pumpkin is an almost 15 year old spayed female kitty who is overweight (16lbs) and was diagnosed as diabetic in 2008 at a previous clinic and was on Vetsulin until 2011, on which the owners felt she was well-regulated clinically (plantigrade stance and significant PU/PD resolved). In 2011 she was switched to PZI and owners saw clinical signs get worse. During that period I only found that fructosamines and spot BG checks were done, and all were always high.
She came to us for a second opinion at that time and we did a chem and CBC. All was normal other than BG at time of that draw was 55, so we ended up decreasing the PZI, getting her onto regular meal feeding on DM, and changed insulin injection site from scruff to flanks. Based on a curve 2 weeks later when she started with a BG of 42 pre-insulin to 241 peak, insulin was discontinued entirely, but was started again 2 weeks later and we tried to manage her on PZI over the next year, with owner doing curves at home. She never was very tightly regulated.
In May 2012 we switched her to glargine and she has been on 3 Units BID since then, despite at one point our recommendation to go up to 4 U based on a curve (the owners are very nervous about increasing the insulin so I think they decided not to).
Last urinalysis and chem panel were Jan 2013 and all was normal other than glucosuria, BUN was high at 44 (CREAT 1.3), and sodium and chloride each mildly low. Fructosamine was high. She was in for a curve shortly after that and started at BG of 250. The owner had not fed the cat that morning at 6:30 and given insulin, like normal, but brought it in with her. We gave 3 U and fed her at 8:00 and by 2pm the BG was 80, at 4pm it was 35. (In the meantime we've learned that we were using the wrong code for these measurements- we have an Alphatrak 1 and are using alphatrak 2 strips, so were supposed to use code 7 instead of what's on the bottle but did not-that causes falsely low values, but still it's too low).
This happened after the owner called at noon to remind us to do the noon feeding. I learned then that she'd been actually feeding 4 meals per day because she was worried about the BG falling too low. I recommended for better control only feeding BID, so did not feed that noon meal while in the clinic, but then over the course of the afternoon the BG dropped and we thought maybe it was Somogyi effect. So we decreased to 2 U Glargine BID and let her kept doing the 4 feedings, but rec that once we get her regulated we try to get her to 2 feedings. We did decrease the amount fed, hoping if we can get her to a healthy weight that will help us regulate.
However, she was back Monday and all readings hovered between approximately 300-320, when done with her normal 6:30 feeding and insulin, along with the 12pm feeding in clinic. She did lose .3 lbs on the decreased feeding, a step in the right directin, but now we increased her back to 3 units. What are we missing here? Owner feels clinical signs are well-controlled (other than she does have diabetic cataracts) but we just can't seem to get her into a normal range. | Usg at this time? | I'm seeking feedback from internal medicine and nutrition on my plan...any suggestions on diet or other thoughts (besides the possibility of renal lymphoma or stones)? |
Hi
I have a 7 year old male neutered Maltese terrier.
He came in with acute onset red urine (found at the groomers). Appetite etc ok, bright happy. no signs of straining or increased urinating.
Physical exam all normal including Prostate on rectal
Urine usg 1.005
Macroscopically bright red
Pro +++
Bili+++
Bld +++
No rbc when spun down. Urine remained red
Sediment normal
C + S - pending
PVC 45 serum red
no sign iof spherocytes or reticulocytes on blood smear
In saline -ve
Initialliy when we spun the PCV down the serum was red. Today it is normal so it may have been iatroogenic yesterday.
Biochem norm including bilirubin, urea, alt
Xrays - unremarkable
Ultrasound prsotate, kidneys normal
Bladder 3mm polyp / mass in mucosal surface of dorsal bladder wall
I am awaiting creatinine kinase and AST blood results. - The lab said they could not run it due to the colour of the serum today I will call hem tomorrow am. Should they be able to run CK and AST on this sample?
Could this be very early IMHA? There is no exposure to onions, garlic, beetroot etc.
I guess beetroot would only change urine not plasma?
What does myoglobin in urine look like microscopically?
Could angiostrongylus cause this?
Could the polyp in the bladder be bleeding and the low USG cause lysis of the RBC in the uirn ebefore he urinate it out?
Could overheating at the groomers cause this level of muscle damage? Would he be painful if it was high enough to cause high CK?
Any other ddx?
Any ideas what could cause such a low USG, could myoglobinuria do this on it's own?
Thanks for your help
☼ | I agree, possibly iatrogenic, or maybe resolved? | Did you look at milk cytology from the gland? |
Hi
I have a 7 year old male neutered Maltese terrier.
He came in with acute onset red urine (found at the groomers). Appetite etc ok, bright happy. no signs of straining or increased urinating.
Physical exam all normal including Prostate on rectal
Urine usg 1.005
Macroscopically bright red
Pro +++
Bili+++
Bld +++
No rbc when spun down. Urine remained red
Sediment normal
C + S - pending
PVC 45 serum red
no sign iof spherocytes or reticulocytes on blood smear
In saline -ve
Initialliy when we spun the PCV down the serum was red. Today it is normal so it may have been iatroogenic yesterday.
Biochem norm including bilirubin, urea, alt
Xrays - unremarkable
Ultrasound prsotate, kidneys normal
Bladder 3mm polyp / mass in mucosal surface of dorsal bladder wall
I am awaiting creatinine kinase and AST blood results. - The lab said they could not run it due to the colour of the serum today I will call hem tomorrow am. Should they be able to run CK and AST on this sample?
Could this be very early IMHA? There is no exposure to onions, garlic, beetroot etc.
I guess beetroot would only change urine not plasma?
What does myoglobin in urine look like microscopically?
Could angiostrongylus cause this?
Could the polyp in the bladder be bleeding and the low USG cause lysis of the RBC in the uirn ebefore he urinate it out?
Could overheating at the groomers cause this level of muscle damage? Would he be painful if it was high enough to cause high CK?
Any other ddx?
Any ideas what could cause such a low USG, could myoglobinuria do this on it's own?
Thanks for your help
☼ | Did you recheck the pcv on this sample? | What insulin is he on? |
Hi
I have a 7 year old male neutered Maltese terrier.
He came in with acute onset red urine (found at the groomers). Appetite etc ok, bright happy. no signs of straining or increased urinating.
Physical exam all normal including Prostate on rectal
Urine usg 1.005
Macroscopically bright red
Pro +++
Bili+++
Bld +++
No rbc when spun down. Urine remained red
Sediment normal
C + S - pending
PVC 45 serum red
no sign iof spherocytes or reticulocytes on blood smear
In saline -ve
Initialliy when we spun the PCV down the serum was red. Today it is normal so it may have been iatroogenic yesterday.
Biochem norm including bilirubin, urea, alt
Xrays - unremarkable
Ultrasound prsotate, kidneys normal
Bladder 3mm polyp / mass in mucosal surface of dorsal bladder wall
I am awaiting creatinine kinase and AST blood results. - The lab said they could not run it due to the colour of the serum today I will call hem tomorrow am. Should they be able to run CK and AST on this sample?
Could this be very early IMHA? There is no exposure to onions, garlic, beetroot etc.
I guess beetroot would only change urine not plasma?
What does myoglobin in urine look like microscopically?
Could angiostrongylus cause this?
Could the polyp in the bladder be bleeding and the low USG cause lysis of the RBC in the uirn ebefore he urinate it out?
Could overheating at the groomers cause this level of muscle damage? Would he be painful if it was high enough to cause high CK?
Any other ddx?
Any ideas what could cause such a low USG, could myoglobinuria do this on it's own?
Thanks for your help
☼ | Any chance you got an additional urine sample as well to see how the urine appears today? | What kind of research is georgia doing? |
Hi
I have a 7 year old male neutered Maltese terrier.
He came in with acute onset red urine (found at the groomers). Appetite etc ok, bright happy. no signs of straining or increased urinating.
Physical exam all normal including Prostate on rectal
Urine usg 1.005
Macroscopically bright red
Pro +++
Bili+++
Bld +++
No rbc when spun down. Urine remained red
Sediment normal
C + S - pending
PVC 45 serum red
no sign iof spherocytes or reticulocytes on blood smear
In saline -ve
Initialliy when we spun the PCV down the serum was red. Today it is normal so it may have been iatroogenic yesterday.
Biochem norm including bilirubin, urea, alt
Xrays - unremarkable
Ultrasound prsotate, kidneys normal
Bladder 3mm polyp / mass in mucosal surface of dorsal bladder wall
I am awaiting creatinine kinase and AST blood results. - The lab said they could not run it due to the colour of the serum today I will call hem tomorrow am. Should they be able to run CK and AST on this sample?
Could this be very early IMHA? There is no exposure to onions, garlic, beetroot etc.
I guess beetroot would only change urine not plasma?
What does myoglobin in urine look like microscopically?
Could angiostrongylus cause this?
Could the polyp in the bladder be bleeding and the low USG cause lysis of the RBC in the uirn ebefore he urinate it out?
Could overheating at the groomers cause this level of muscle damage? Would he be painful if it was high enough to cause high CK?
Any other ddx?
Any ideas what could cause such a low USG, could myoglobinuria do this on it's own?
Thanks for your help
☼ | Would you be able to post these results? | What are the albumin /total protein looking like? |
Hi
I have a 7 year old male neutered Maltese terrier.
He came in with acute onset red urine (found at the groomers). Appetite etc ok, bright happy. no signs of straining or increased urinating.
Physical exam all normal including Prostate on rectal
Urine usg 1.005
Macroscopically bright red
Pro +++
Bili+++
Bld +++
No rbc when spun down. Urine remained red
Sediment normal
C + S - pending
PVC 45 serum red
no sign iof spherocytes or reticulocytes on blood smear
In saline -ve
Initialliy when we spun the PCV down the serum was red. Today it is normal so it may have been iatroogenic yesterday.
Biochem norm including bilirubin, urea, alt
Xrays - unremarkable
Ultrasound prsotate, kidneys normal
Bladder 3mm polyp / mass in mucosal surface of dorsal bladder wall
I am awaiting creatinine kinase and AST blood results. - The lab said they could not run it due to the colour of the serum today I will call hem tomorrow am. Should they be able to run CK and AST on this sample?
Could this be very early IMHA? There is no exposure to onions, garlic, beetroot etc.
I guess beetroot would only change urine not plasma?
What does myoglobin in urine look like microscopically?
Could angiostrongylus cause this?
Could the polyp in the bladder be bleeding and the low USG cause lysis of the RBC in the uirn ebefore he urinate it out?
Could overheating at the groomers cause this level of muscle damage? Would he be painful if it was high enough to cause high CK?
Any other ddx?
Any ideas what could cause such a low USG, could myoglobinuria do this on it's own?
Thanks for your help
☼ | I am assuming abdominal x-rays? | My question is why did this animal have an ulcer in the first place? |
Hi
I have a 7 year old male neutered Maltese terrier.
He came in with acute onset red urine (found at the groomers). Appetite etc ok, bright happy. no signs of straining or increased urinating.
Physical exam all normal including Prostate on rectal
Urine usg 1.005
Macroscopically bright red
Pro +++
Bili+++
Bld +++
No rbc when spun down. Urine remained red
Sediment normal
C + S - pending
PVC 45 serum red
no sign iof spherocytes or reticulocytes on blood smear
In saline -ve
Initialliy when we spun the PCV down the serum was red. Today it is normal so it may have been iatroogenic yesterday.
Biochem norm including bilirubin, urea, alt
Xrays - unremarkable
Ultrasound prsotate, kidneys normal
Bladder 3mm polyp / mass in mucosal surface of dorsal bladder wall
I am awaiting creatinine kinase and AST blood results. - The lab said they could not run it due to the colour of the serum today I will call hem tomorrow am. Should they be able to run CK and AST on this sample?
Could this be very early IMHA? There is no exposure to onions, garlic, beetroot etc.
I guess beetroot would only change urine not plasma?
What does myoglobin in urine look like microscopically?
Could angiostrongylus cause this?
Could the polyp in the bladder be bleeding and the low USG cause lysis of the RBC in the uirn ebefore he urinate it out?
Could overheating at the groomers cause this level of muscle damage? Would he be painful if it was high enough to cause high CK?
Any other ddx?
Any ideas what could cause such a low USG, could myoglobinuria do this on it's own?
Thanks for your help
☼ | Can you post these as well? | Was the front door or a back door? |
Buddha - 9 month old male, neutered pug mix has been PU/PD last few months - UA - usg 1.006, rod bacteria noted on microscopic exam, but negative on culture; BUN 29, Creat 1.2, Phos 6.4; CBC - nsf, Urine Lepto PCR - Positive, Ultrasound of abdomen - nsf. Started on 2 weeks of doxycycline. Owners were counseled to speak to their health care providers since they were cleaning up urine in the house quite frequently.
Owner became very sick about 1 week into therapy and was unable to give meds as directed and patient only received doxycycline once a day.
Here we are 2 weeks later and patient is still PU/PD and I don't know if the poor owner compliance in the second week of therapy leaves us open to ongoing lepto infection. Or how long we can expect the kidneys to be poorly concentrating if they are going to recover. Or if he has lepto exposure along with having diabetes insipidus...
So - we are repeating the antibiotics with better compliance and giving it more time.
Any other thoughts? | Have we ever done titers on the dog? | Is this the dry version? |
One of my patients is a 14 yr old MN DSH cat who has been FIV positive since at least 2 years of age. For the past year, the owner has complained of polyphagia and weight loss. I have run bloodwork on 2-3 occasions and each time the thyroid level has been mid-range to low normal . The cat's HR is in the 180 range and he does not have a palpable thyroid goiter. His BG is also normal at 105 on the most recent bloodwork. BUN and creatinine are also normal but his urine specific gravity was 1.015 despite being visibly dehydrated. His ALT was elevated mild to moderately at 215. His hematocrit was low normal at 31.7% although I suspect this dropped after diuresis.
When the cat presented 2 days ago, the owner's main complaint was still the polyphagia. He also stated that the cat seems cold all the time (his rectal temp was 96.8 on presentation). While thin, he has remained in the 7 lb range for the past 8-12 months. He was so dehydrated when he came in, that I had to hospitalize him on IV fluids to obtain blood. Despite this, the owner swears he is drinking and eating well at home.
I warned the owner that I was concerned about neoplasia (specifically lymphoma) given the cat's age and FIV positive status. He declined radiographs at this visit and is unlikely to pursue invasive diagnostic procedures. I was wondering if anyone had any thoughts or suggestions. Since the cat seems to be eating well at home and not so great in the hospital, I sent him home with SQ fluids to be administered and I will recheck the cat in a week or so. | Has there been vomiting (including "hairballs"), diarrhea, constipation, etc.? | Is this kitty still eating the canned m/d? |
One of my patients is a 14 yr old MN DSH cat who has been FIV positive since at least 2 years of age. For the past year, the owner has complained of polyphagia and weight loss. I have run bloodwork on 2-3 occasions and each time the thyroid level has been mid-range to low normal . The cat's HR is in the 180 range and he does not have a palpable thyroid goiter. His BG is also normal at 105 on the most recent bloodwork. BUN and creatinine are also normal but his urine specific gravity was 1.015 despite being visibly dehydrated. His ALT was elevated mild to moderately at 215. His hematocrit was low normal at 31.7% although I suspect this dropped after diuresis.
When the cat presented 2 days ago, the owner's main complaint was still the polyphagia. He also stated that the cat seems cold all the time (his rectal temp was 96.8 on presentation). While thin, he has remained in the 7 lb range for the past 8-12 months. He was so dehydrated when he came in, that I had to hospitalize him on IV fluids to obtain blood. Despite this, the owner swears he is drinking and eating well at home.
I warned the owner that I was concerned about neoplasia (specifically lymphoma) given the cat's age and FIV positive status. He declined radiographs at this visit and is unlikely to pursue invasive diagnostic procedures. I was wondering if anyone had any thoughts or suggestions. Since the cat seems to be eating well at home and not so great in the hospital, I sent him home with SQ fluids to be administered and I will recheck the cat in a week or so. | Is he pu/pd? | Pu/pd controlled? |
One of my patients is a 14 yr old MN DSH cat who has been FIV positive since at least 2 years of age. For the past year, the owner has complained of polyphagia and weight loss. I have run bloodwork on 2-3 occasions and each time the thyroid level has been mid-range to low normal . The cat's HR is in the 180 range and he does not have a palpable thyroid goiter. His BG is also normal at 105 on the most recent bloodwork. BUN and creatinine are also normal but his urine specific gravity was 1.015 despite being visibly dehydrated. His ALT was elevated mild to moderately at 215. His hematocrit was low normal at 31.7% although I suspect this dropped after diuresis.
When the cat presented 2 days ago, the owner's main complaint was still the polyphagia. He also stated that the cat seems cold all the time (his rectal temp was 96.8 on presentation). While thin, he has remained in the 7 lb range for the past 8-12 months. He was so dehydrated when he came in, that I had to hospitalize him on IV fluids to obtain blood. Despite this, the owner swears he is drinking and eating well at home.
I warned the owner that I was concerned about neoplasia (specifically lymphoma) given the cat's age and FIV positive status. He declined radiographs at this visit and is unlikely to pursue invasive diagnostic procedures. I was wondering if anyone had any thoughts or suggestions. Since the cat seems to be eating well at home and not so great in the hospital, I sent him home with SQ fluids to be administered and I will recheck the cat in a week or so. | What does he eat? | If there are no supportive signs it might be an incidental find? |
Poot is a 12 yr nm min pin that is diabetic. His diabetes is regulated believe it or not but we have been struggling with chronic UTIs of e. coli and more recently pseudomonas that we are able to culture out even while on antibiotics. We are using sterile red rubber catheters to collect our samples. He is not Cushinoid. An ultrasound of his bladder shows thin walls, no tumors, no stones, no enlarged prostate and fairly normal kidneys. We started with clavamox, then moved on to doxy based on C and S and are now using Baytril. I even used some TMPS despite him being a min pin. No problems with it. This last culture grew psuedomonas only; no ecoli; but I feel like we'll see it again on the next culture. He is currently weighing 11 # andis on 3 1/2 u of insulin and on 34mg of Baytril. I could certainly go up on the dose but wanted to get some input from you guys of where to go next.
Thanks
☼ | How long are you treating these infections for? | Nph would be more cost-effective for a bigger dog--not sure why she's on the vetsulin? |
Poot is a 12 yr nm min pin that is diabetic. His diabetes is regulated believe it or not but we have been struggling with chronic UTIs of e. coli and more recently pseudomonas that we are able to culture out even while on antibiotics. We are using sterile red rubber catheters to collect our samples. He is not Cushinoid. An ultrasound of his bladder shows thin walls, no tumors, no stones, no enlarged prostate and fairly normal kidneys. We started with clavamox, then moved on to doxy based on C and S and are now using Baytril. I even used some TMPS despite him being a min pin. No problems with it. This last culture grew psuedomonas only; no ecoli; but I feel like we'll see it again on the next culture. He is currently weighing 11 # andis on 3 1/2 u of insulin and on 34mg of Baytril. I could certainly go up on the dose but wanted to get some input from you guys of where to go next.
Thanks
☼ | When do you culture? | The owner can accurately measure and then inject the insulin ...using the u40 syringes? |
Poot is a 12 yr nm min pin that is diabetic. His diabetes is regulated believe it or not but we have been struggling with chronic UTIs of e. coli and more recently pseudomonas that we are able to culture out even while on antibiotics. We are using sterile red rubber catheters to collect our samples. He is not Cushinoid. An ultrasound of his bladder shows thin walls, no tumors, no stones, no enlarged prostate and fairly normal kidneys. We started with clavamox, then moved on to doxy based on C and S and are now using Baytril. I even used some TMPS despite him being a min pin. No problems with it. This last culture grew psuedomonas only; no ecoli; but I feel like we'll see it again on the next culture. He is currently weighing 11 # andis on 3 1/2 u of insulin and on 34mg of Baytril. I could certainly go up on the dose but wanted to get some input from you guys of where to go next.
Thanks
☼ | Before, during, and after completion of antibiotics? | Does he have any gi signs? |
Poot is a 12 yr nm min pin that is diabetic. His diabetes is regulated believe it or not but we have been struggling with chronic UTIs of e. coli and more recently pseudomonas that we are able to culture out even while on antibiotics. We are using sterile red rubber catheters to collect our samples. He is not Cushinoid. An ultrasound of his bladder shows thin walls, no tumors, no stones, no enlarged prostate and fairly normal kidneys. We started with clavamox, then moved on to doxy based on C and S and are now using Baytril. I even used some TMPS despite him being a min pin. No problems with it. This last culture grew psuedomonas only; no ecoli; but I feel like we'll see it again on the next culture. He is currently weighing 11 # andis on 3 1/2 u of insulin and on 34mg of Baytril. I could certainly go up on the dose but wanted to get some input from you guys of where to go next.
Thanks
☼ | Are you able to get a cystocentesis for samples for this dog just to eliminate any chance of contamination from the catheter? | How's his usg? |
Mercedes is an 8 year old spayed female indoor cat that has always been highly aggressive during her vet visits. She has been aggressive at home towards her owner as well. She has chronic waxy, itchy otitis and allergic skin sease which is partially responisve to hypoallergenic et and is steroid responsive. When she was on prednisolone a year ago, the owner felt that it made her more aggressive. We switched her to dexamethasone and her mood vastly improved. However, the owner reports that if he misses 2 consecutive doses, "she becomes feral".She has been on 0.5mg po bid for a year at this point. In adtion, she has had at least 2 episodes of likely stress-induced stranguria and hematuria, which has not recurred in the past year.
I asked the owner about possible hyperesthesia-type symptoms and it sounds like he has observed this a couple of times, but nothing that is frequent.
I examined her yesterday for vomiting 1-2 times daily for the past 3 days. The exam (fairly complete) was unremarkable. cbc/chem/T4/SpecfPL all wnl. She would need sedative for anything else.
I am concerned about the long term use of dexamethasone and have not observed this profound behavioral side effect. I am wondering about trying Elavil for possible hyperethesia but don't want to put the owner at risk of being injured by his cat. I also wonder if she is so sensitive to stress and allergens that it may also be causing the current vomiting.
Any thoughts on this would be appreciated.
Thanks
☼ | So perhaps this could relate more to a mildly pruritic skin at times? | Can you give us the results of direct and consensual responses in both eyes? |
My patient is a 9-year-old MC miniature schnauzer who recently transferred from another clinic. Was diagnosed with diabetes in November 2011, have never done a curve, was regulated based on BG spot checks. Takes 14 units Novolin N BID. Eats W/D diet. Huge appetite, can never seem to get enough. Very PU/PD. Has cataracts OU. Sparse hair coat but no calcinosis cutis.
Routine lab work last month showed:
A/G Ratio 0.8 0.6 1.6
Albumin 3.0 2.5 4.0
Alk. Phosphatase 635 10 150
Alt (sgpt) 52 5 107
Amylase 594 450 1240
Anion Gap 25 12 24
Ast (sgot) 28 5 55
B/C Ratio 30.0
Bun 18 7 27
Calcium 10.7 8.2 12.4
Chloride 102 105 115
Cholesterol 258 112 328
Ck 122 10 200
Creatinine 0.6 0.4 1.8
Direct Bilirubin 0.0 0.0 0.2
Ggt 11 0 14
Globulin 3.6 2.1 4.5
Glucose 80 60 125
Hemolysis Index ++
Indirect Bilirubin 0.0 0 0.3
Lipase 576 100 750
Lipemia Index N
Na/K Ratio 32 27 40
Phosphorus 4.7 2.1 6.3
Potassium 4.5 4.0 5.6
Sodium 146 141 156
Tco2 (bicarbonate) 24 17 24
Total Bilirubin 0.0 0.0 0.4
Total Protein 6.6 5.1 7.8 Specimen Required Ultracentrifugation Due To Gross Lipemia. (Really? In a schnauzer?)
Based on high alk phos and symptoms I ran a Low Dose Dex Suppression test yesterday. (Alas, I had not done my VIN reading yet and I did not realize that this test has so many false positives in diabetics.)
The results were:
Pre-Dex 7.6 (ref 1.0 - 6.0 mcg/dL)
4 hours post 0.8
8 hours post 2.2
According to Idexx, this confirms PDH.
So, is this dog just a poorly-regulated diabetic or does he have Cushing's, too? What do I now recommend to the client that does not waste her money (again) and has the best chance of helping the patient? BG curve and hold off on treatment for Cushing's?
Advice would be greatly appreciated. Thanks! | What is this dog's weight? | The skin issues you describe, do they include itchiness? |
Chopper is a 8yr MC pug. He originally presented in 9/12 for vomiting and weight loss. He was treated at a 24 hour referral center for diabetic ketosis and severe necrotizing pancreatitis. He also began treatment for bilateral corneal ulcers secondary to KCS.
10.3.12: wt = 31.7#. Approximately 2 weeks after he was discharged from the referral center, he presented to our hospital for a glucose curve. He had been on 5U of Humulin N insulin BID. The owner was not sure if she had given the insulin the previous night.
9:54 (pre-insulin glucose) - 575, patient was given 5U of Humulin N insulin SQ
10:55 - 486
12:55 - 195
1:55 - 165
3:55 - 260
TP, ALB, GLOB, TBIL - WNL
ALT - 103 (10-100)
ALKP - 446 (23-212)
urine ketones - negative
Physical exam - corneal edema OD with vascularization, corneal melanosis OU, normal auscultation, mild jaundice.
After discussion with the doctor that treated Chopper at the referral center, it was agreed to continue his insulin at 5U BID, and to recheck his glucose curve in 3 months and his liver values in 1 month.
After consultation with a Hill's veterinarian, to determine the best diet for Chopper's combination of issues, we began him on the w/d dry and lowfat i/d canned.
1.9.13: wt = 27.2# Glucose curve
9:50 (pre-insulin glucose) - 563, patient was given 5U of Humulin N insulin SQ
10:45 - 550
12:45 - 484
2:45 - 514
4:45 - 416
6:45 - 355
Physical exam - BCS 6/9, corneal melanosis OU, ~3mm smooth round lump medial 2nd digit LTL (present for a while and unchanged per o), rest WNL
The insulin was increased to 6U BID
2.13.13: wt = 28# Glucose curve
9:48 (pre-insulin) - 143, insulin was not given but curve was continued to be sure glucose did not drop too low throughout the day, discussed concern for possible insulinoma vs too high of an insulin dose
12:00 - 259
2:00 - 606
4:00 - 695
Physical exam - BAR, unchanged
The insulin was decreased to 5U BID, discussed likely presence of complicating factors to regulation, infection vs residual from pancreatitis, neoplasia. O elected not to work up for other factors, as dog was doing well clinically at home.
2.21.13: wt = 28.8# Owner noticed 2 days ago that dog started walking into things. Also noticed that he is eating well, but approximately 15 minutes after receiving his insulin he falls alseep and will be "zonked" for an hour or two. He is always responsive and wakes up if called, but then will go back to bed.
Physical exam: normal PLR OU (direct and consensual) and cataracts OU, but difficult to assess much else beyond corneas due to melanosis. Normal retropulsion. Menace was absent, but he was able to follow a cotton ball from side to side, not up and down, and doesn't see it if tossed directly at him. He almost walked off the table twice and would stare at the wall when sitting on the floor. Chopper was BAR and the rest of his examination was WNL (other than the unchanged mass on his LTL toe).
The owner is going to purchase a glucometer to track his glucose at home, particularly during his "sleepy" episodes. We discussed that the vision issues may just be due to his cataracts and the obstruction of the corneal melanosis. Because he was so sick, I want to make sure I am not forgetting something big in him. It seemed like a very acute presentation, but was he just compensating for a while before it became too much for him to adapt to? I know we should do a urine culture to rule out infection as an issue for regulation, but the owner has so far declined. Along with recommending that again, would it be worthwhile repeating an abdominal ultrasound? We talked some about referral for an ophtho consult. Any advice regarding Chopper is appreciated. | Are there any steroids being used in the eyes? | Urine c/s? |
Chopper is a 8yr MC pug. He originally presented in 9/12 for vomiting and weight loss. He was treated at a 24 hour referral center for diabetic ketosis and severe necrotizing pancreatitis. He also began treatment for bilateral corneal ulcers secondary to KCS.
10.3.12: wt = 31.7#. Approximately 2 weeks after he was discharged from the referral center, he presented to our hospital for a glucose curve. He had been on 5U of Humulin N insulin BID. The owner was not sure if she had given the insulin the previous night.
9:54 (pre-insulin glucose) - 575, patient was given 5U of Humulin N insulin SQ
10:55 - 486
12:55 - 195
1:55 - 165
3:55 - 260
TP, ALB, GLOB, TBIL - WNL
ALT - 103 (10-100)
ALKP - 446 (23-212)
urine ketones - negative
Physical exam - corneal edema OD with vascularization, corneal melanosis OU, normal auscultation, mild jaundice.
After discussion with the doctor that treated Chopper at the referral center, it was agreed to continue his insulin at 5U BID, and to recheck his glucose curve in 3 months and his liver values in 1 month.
After consultation with a Hill's veterinarian, to determine the best diet for Chopper's combination of issues, we began him on the w/d dry and lowfat i/d canned.
1.9.13: wt = 27.2# Glucose curve
9:50 (pre-insulin glucose) - 563, patient was given 5U of Humulin N insulin SQ
10:45 - 550
12:45 - 484
2:45 - 514
4:45 - 416
6:45 - 355
Physical exam - BCS 6/9, corneal melanosis OU, ~3mm smooth round lump medial 2nd digit LTL (present for a while and unchanged per o), rest WNL
The insulin was increased to 6U BID
2.13.13: wt = 28# Glucose curve
9:48 (pre-insulin) - 143, insulin was not given but curve was continued to be sure glucose did not drop too low throughout the day, discussed concern for possible insulinoma vs too high of an insulin dose
12:00 - 259
2:00 - 606
4:00 - 695
Physical exam - BAR, unchanged
The insulin was decreased to 5U BID, discussed likely presence of complicating factors to regulation, infection vs residual from pancreatitis, neoplasia. O elected not to work up for other factors, as dog was doing well clinically at home.
2.21.13: wt = 28.8# Owner noticed 2 days ago that dog started walking into things. Also noticed that he is eating well, but approximately 15 minutes after receiving his insulin he falls alseep and will be "zonked" for an hour or two. He is always responsive and wakes up if called, but then will go back to bed.
Physical exam: normal PLR OU (direct and consensual) and cataracts OU, but difficult to assess much else beyond corneas due to melanosis. Normal retropulsion. Menace was absent, but he was able to follow a cotton ball from side to side, not up and down, and doesn't see it if tossed directly at him. He almost walked off the table twice and would stare at the wall when sitting on the floor. Chopper was BAR and the rest of his examination was WNL (other than the unchanged mass on his LTL toe).
The owner is going to purchase a glucometer to track his glucose at home, particularly during his "sleepy" episodes. We discussed that the vision issues may just be due to his cataracts and the obstruction of the corneal melanosis. Because he was so sick, I want to make sure I am not forgetting something big in him. It seemed like a very acute presentation, but was he just compensating for a while before it became too much for him to adapt to? I know we should do a urine culture to rule out infection as an issue for regulation, but the owner has so far declined. Along with recommending that again, would it be worthwhile repeating an abdominal ultrasound? We talked some about referral for an ophtho consult. Any advice regarding Chopper is appreciated. | Which one? | What's going to happen to the dog when the owner leaves on sunday? |
We had a 9yr F/S bichon on pred 1mg/kg/day and cyclosporine 4mg/kg/day for severe atopy and IBD. She also had an elevated ALT at 480. The dog was on the pred long term, and the cyclosporine for 4 months.
1/24/13- she presented with a small 3mm2superficial wound on the L front leg, lateral 4th digit adjacent to the pad margin.
1/26/13- 3 days later the wound was 1x1x.5cm. Aspirates came back as pyogranulomatous inflammation with numerous fungal hyphae/organisms-mycetoma. The dog was taken off of cyclosporine, the pred weaned down over 2 weeks and stopped, and budesonide started 1mg SID. Fluconazole 5mg/kg BID and terbinafine 10mg/kg SID were also started, and miconazole topically. At the same time the owner was in the hospital, and the grandma was taking care of the dog.
2/16/13 - the entire L front leg from the elbow distally was swollen, draining pus in several places, including over the carpus and dorsal to toes. Drains were placed, the leg soaked twice daily in dilute betadine to encourage drainage, and fluconazole changed to 5mg/kg sporonox BID. Continued with terbinafine.
cytology enlarged L prescap lymph node- reactive, no fungal organisms seen
chest rads clear, L forelimb rads- periosteal reaction of P2 4th digit- poss osteomyelitis
Anerobic culture- no growth
aerobic culture- scant normal skin flora
fungal culture- no growth after 6 days
cytology- pyogran. inflammation with intracellular branching septate fungal hyphae, generally negative staining, some with very pale coloration
skin biopsies- fragments of fungal hyphae are found along the deep edges of the specimens, which presumably represents the wall of a draining tract. The fungi are broad, septate, slightly variable in width, and have a few bulbous thickenings. Macroconidia are not present. The fungal shape is suggstive of organisms of the order mucorales
It is has been one week on the itraconazole. The area from the carpus to the elbow appears improved with less drainage, but the foot area appears worse with copius drainage and swelling. The dog is otherwise fine- eating well. Not limping.
How long will this fungal culture take for a opportunistic fungus? The lab said up to 4 weeks. I was reading the human lit and mucor organisms are very aggressive, the azoles don't work well, they use surgical debridement/amputation, positrex and liposome ampho B.
Should I change treatment based on the histo alone and not a definitive fungal culture? What doses are appropriate? How long to wait until I decide to amputate? I would have to remove the leg at the shoulder.I would hate to wait to long and have this disseminate throughout her body.
thanks for your help on this frustrating case! br/y
Brook-Falls Veterinary Hospital & Exotic Care Inc
Menomonee Falls. WI | Once a dilute the bottle, can i use it for a few doses if i keep it in the frig? | When you ran the stim at 1 month on the vetoryl, was it started 3-5 hours after the trilosane was given with food that morning, cortrosyn was used and the samples went to a commercial lab? |
We had a 9yr F/S bichon on pred 1mg/kg/day and cyclosporine 4mg/kg/day for severe atopy and IBD. She also had an elevated ALT at 480. The dog was on the pred long term, and the cyclosporine for 4 months.
1/24/13- she presented with a small 3mm2superficial wound on the L front leg, lateral 4th digit adjacent to the pad margin.
1/26/13- 3 days later the wound was 1x1x.5cm. Aspirates came back as pyogranulomatous inflammation with numerous fungal hyphae/organisms-mycetoma. The dog was taken off of cyclosporine, the pred weaned down over 2 weeks and stopped, and budesonide started 1mg SID. Fluconazole 5mg/kg BID and terbinafine 10mg/kg SID were also started, and miconazole topically. At the same time the owner was in the hospital, and the grandma was taking care of the dog.
2/16/13 - the entire L front leg from the elbow distally was swollen, draining pus in several places, including over the carpus and dorsal to toes. Drains were placed, the leg soaked twice daily in dilute betadine to encourage drainage, and fluconazole changed to 5mg/kg sporonox BID. Continued with terbinafine.
cytology enlarged L prescap lymph node- reactive, no fungal organisms seen
chest rads clear, L forelimb rads- periosteal reaction of P2 4th digit- poss osteomyelitis
Anerobic culture- no growth
aerobic culture- scant normal skin flora
fungal culture- no growth after 6 days
cytology- pyogran. inflammation with intracellular branching septate fungal hyphae, generally negative staining, some with very pale coloration
skin biopsies- fragments of fungal hyphae are found along the deep edges of the specimens, which presumably represents the wall of a draining tract. The fungi are broad, septate, slightly variable in width, and have a few bulbous thickenings. Macroconidia are not present. The fungal shape is suggstive of organisms of the order mucorales
It is has been one week on the itraconazole. The area from the carpus to the elbow appears improved with less drainage, but the foot area appears worse with copius drainage and swelling. The dog is otherwise fine- eating well. Not limping.
How long will this fungal culture take for a opportunistic fungus? The lab said up to 4 weeks. I was reading the human lit and mucor organisms are very aggressive, the azoles don't work well, they use surgical debridement/amputation, positrex and liposome ampho B.
Should I change treatment based on the histo alone and not a definitive fungal culture? What doses are appropriate? How long to wait until I decide to amputate? I would have to remove the leg at the shoulder.I would hate to wait to long and have this disseminate throughout her body.
thanks for your help on this frustrating case! br/y
Brook-Falls Veterinary Hospital & Exotic Care Inc
Menomonee Falls. WI | Is this what i should do and stop the itraconazole? | Are they moving the injections around on his body every day? |
We had a 9yr F/S bichon on pred 1mg/kg/day and cyclosporine 4mg/kg/day for severe atopy and IBD. She also had an elevated ALT at 480. The dog was on the pred long term, and the cyclosporine for 4 months.
1/24/13- she presented with a small 3mm2superficial wound on the L front leg, lateral 4th digit adjacent to the pad margin.
1/26/13- 3 days later the wound was 1x1x.5cm. Aspirates came back as pyogranulomatous inflammation with numerous fungal hyphae/organisms-mycetoma. The dog was taken off of cyclosporine, the pred weaned down over 2 weeks and stopped, and budesonide started 1mg SID. Fluconazole 5mg/kg BID and terbinafine 10mg/kg SID were also started, and miconazole topically. At the same time the owner was in the hospital, and the grandma was taking care of the dog.
2/16/13 - the entire L front leg from the elbow distally was swollen, draining pus in several places, including over the carpus and dorsal to toes. Drains were placed, the leg soaked twice daily in dilute betadine to encourage drainage, and fluconazole changed to 5mg/kg sporonox BID. Continued with terbinafine.
cytology enlarged L prescap lymph node- reactive, no fungal organisms seen
chest rads clear, L forelimb rads- periosteal reaction of P2 4th digit- poss osteomyelitis
Anerobic culture- no growth
aerobic culture- scant normal skin flora
fungal culture- no growth after 6 days
cytology- pyogran. inflammation with intracellular branching septate fungal hyphae, generally negative staining, some with very pale coloration
skin biopsies- fragments of fungal hyphae are found along the deep edges of the specimens, which presumably represents the wall of a draining tract. The fungi are broad, septate, slightly variable in width, and have a few bulbous thickenings. Macroconidia are not present. The fungal shape is suggstive of organisms of the order mucorales
It is has been one week on the itraconazole. The area from the carpus to the elbow appears improved with less drainage, but the foot area appears worse with copius drainage and swelling. The dog is otherwise fine- eating well. Not limping.
How long will this fungal culture take for a opportunistic fungus? The lab said up to 4 weeks. I was reading the human lit and mucor organisms are very aggressive, the azoles don't work well, they use surgical debridement/amputation, positrex and liposome ampho B.
Should I change treatment based on the histo alone and not a definitive fungal culture? What doses are appropriate? How long to wait until I decide to amputate? I would have to remove the leg at the shoulder.I would hate to wait to long and have this disseminate throughout her body.
thanks for your help on this frustrating case! br/y
Brook-Falls Veterinary Hospital & Exotic Care Inc
Menomonee Falls. WI | Should we amputate her leg? | Was it gradually worked up to or did the owner just one day withhold water? |
We had a 9yr F/S bichon on pred 1mg/kg/day and cyclosporine 4mg/kg/day for severe atopy and IBD. She also had an elevated ALT at 480. The dog was on the pred long term, and the cyclosporine for 4 months.
1/24/13- she presented with a small 3mm2superficial wound on the L front leg, lateral 4th digit adjacent to the pad margin.
1/26/13- 3 days later the wound was 1x1x.5cm. Aspirates came back as pyogranulomatous inflammation with numerous fungal hyphae/organisms-mycetoma. The dog was taken off of cyclosporine, the pred weaned down over 2 weeks and stopped, and budesonide started 1mg SID. Fluconazole 5mg/kg BID and terbinafine 10mg/kg SID were also started, and miconazole topically. At the same time the owner was in the hospital, and the grandma was taking care of the dog.
2/16/13 - the entire L front leg from the elbow distally was swollen, draining pus in several places, including over the carpus and dorsal to toes. Drains were placed, the leg soaked twice daily in dilute betadine to encourage drainage, and fluconazole changed to 5mg/kg sporonox BID. Continued with terbinafine.
cytology enlarged L prescap lymph node- reactive, no fungal organisms seen
chest rads clear, L forelimb rads- periosteal reaction of P2 4th digit- poss osteomyelitis
Anerobic culture- no growth
aerobic culture- scant normal skin flora
fungal culture- no growth after 6 days
cytology- pyogran. inflammation with intracellular branching septate fungal hyphae, generally negative staining, some with very pale coloration
skin biopsies- fragments of fungal hyphae are found along the deep edges of the specimens, which presumably represents the wall of a draining tract. The fungi are broad, septate, slightly variable in width, and have a few bulbous thickenings. Macroconidia are not present. The fungal shape is suggstive of organisms of the order mucorales
It is has been one week on the itraconazole. The area from the carpus to the elbow appears improved with less drainage, but the foot area appears worse with copius drainage and swelling. The dog is otherwise fine- eating well. Not limping.
How long will this fungal culture take for a opportunistic fungus? The lab said up to 4 weeks. I was reading the human lit and mucor organisms are very aggressive, the azoles don't work well, they use surgical debridement/amputation, positrex and liposome ampho B.
Should I change treatment based on the histo alone and not a definitive fungal culture? What doses are appropriate? How long to wait until I decide to amputate? I would have to remove the leg at the shoulder.I would hate to wait to long and have this disseminate throughout her body.
thanks for your help on this frustrating case! br/y
Brook-Falls Veterinary Hospital & Exotic Care Inc
Menomonee Falls. WI | Any thoughts on this case please? | Thanks very much! have you tried this diet? |
Patient is a 13-year-old FS DSH, weighing 9.0lbs. BCS 5/9, so she is not your typical fat-cat diabetic.
First diagnosed December 2012. She had CBC, serum chemistries, T4 and urinalysis at that time. All parameters were normal, except glucose = 312, and 3+ glucosuria. Remainder of urinalysis was bland & benign.
She was started on Prozinc, 2 units SQ every 12 hours. This cat has been very difficult to regulate. The owners are very diligent about checking the glucose at home and have crazy results. Sometimes their ipet meter reads 500 or more. One evening recently, it read 48. They did not give insulin that night. Her appetite is consistently good.
We have compared their meter to our Alphtrak and it is usually close, though not always not exactly the same, so I feel their home readings are reasonably accurate.
Her last in-hospital curve on Jan 7 was pretty good.
9am = 449 (408 on their meter)
11am = 331 (their meter’s battery kaput)
1pm = 227
3pm = 133
5pm = 138
Fructosamine on Feb 16 = 516, indicating poor control.
Urine culture and Bartonella test are pending.
Should I try Lantus?
Should I try glipizide? (have another cat on it that is doing well.)
Any other suggestions?
My perspective on diabetics (especially cats) is that beta-cell loss is progressive, and insulin efficacy is cumulative, so maybe we just need to be more patient?!
Thank you. | What diet is she on? | Perhaps sort it out on a case by case basis depending on client? |
Patient is a 13-year-old FS DSH, weighing 9.0lbs. BCS 5/9, so she is not your typical fat-cat diabetic.
First diagnosed December 2012. She had CBC, serum chemistries, T4 and urinalysis at that time. All parameters were normal, except glucose = 312, and 3+ glucosuria. Remainder of urinalysis was bland & benign.
She was started on Prozinc, 2 units SQ every 12 hours. This cat has been very difficult to regulate. The owners are very diligent about checking the glucose at home and have crazy results. Sometimes their ipet meter reads 500 or more. One evening recently, it read 48. They did not give insulin that night. Her appetite is consistently good.
We have compared their meter to our Alphtrak and it is usually close, though not always not exactly the same, so I feel their home readings are reasonably accurate.
Her last in-hospital curve on Jan 7 was pretty good.
9am = 449 (408 on their meter)
11am = 331 (their meter’s battery kaput)
1pm = 227
3pm = 133
5pm = 138
Fructosamine on Feb 16 = 516, indicating poor control.
Urine culture and Bartonella test are pending.
Should I try Lantus?
Should I try glipizide? (have another cat on it that is doing well.)
Any other suggestions?
My perspective on diabetics (especially cats) is that beta-cell loss is progressive, and insulin efficacy is cumulative, so maybe we just need to be more patient?!
Thank you. | Is it the canned-only version of a high protein/low carb diet? | Other ddx for the mass include an aldosterone (potassium level is normal? |
Patient is a 13-year-old FS DSH, weighing 9.0lbs. BCS 5/9, so she is not your typical fat-cat diabetic.
First diagnosed December 2012. She had CBC, serum chemistries, T4 and urinalysis at that time. All parameters were normal, except glucose = 312, and 3+ glucosuria. Remainder of urinalysis was bland & benign.
She was started on Prozinc, 2 units SQ every 12 hours. This cat has been very difficult to regulate. The owners are very diligent about checking the glucose at home and have crazy results. Sometimes their ipet meter reads 500 or more. One evening recently, it read 48. They did not give insulin that night. Her appetite is consistently good.
We have compared their meter to our Alphtrak and it is usually close, though not always not exactly the same, so I feel their home readings are reasonably accurate.
Her last in-hospital curve on Jan 7 was pretty good.
9am = 449 (408 on their meter)
11am = 331 (their meter’s battery kaput)
1pm = 227
3pm = 133
5pm = 138
Fructosamine on Feb 16 = 516, indicating poor control.
Urine culture and Bartonella test are pending.
Should I try Lantus?
Should I try glipizide? (have another cat on it that is doing well.)
Any other suggestions?
My perspective on diabetics (especially cats) is that beta-cell loss is progressive, and insulin efficacy is cumulative, so maybe we just need to be more patient?!
Thank you. | Which one? | Have you looked at cobalamin? |
Patient is a 13-year-old FS DSH, weighing 9.0lbs. BCS 5/9, so she is not your typical fat-cat diabetic.
First diagnosed December 2012. She had CBC, serum chemistries, T4 and urinalysis at that time. All parameters were normal, except glucose = 312, and 3+ glucosuria. Remainder of urinalysis was bland & benign.
She was started on Prozinc, 2 units SQ every 12 hours. This cat has been very difficult to regulate. The owners are very diligent about checking the glucose at home and have crazy results. Sometimes their ipet meter reads 500 or more. One evening recently, it read 48. They did not give insulin that night. Her appetite is consistently good.
We have compared their meter to our Alphtrak and it is usually close, though not always not exactly the same, so I feel their home readings are reasonably accurate.
Her last in-hospital curve on Jan 7 was pretty good.
9am = 449 (408 on their meter)
11am = 331 (their meter’s battery kaput)
1pm = 227
3pm = 133
5pm = 138
Fructosamine on Feb 16 = 516, indicating poor control.
Urine culture and Bartonella test are pending.
Should I try Lantus?
Should I try glipizide? (have another cat on it that is doing well.)
Any other suggestions?
My perspective on diabetics (especially cats) is that beta-cell loss is progressive, and insulin efficacy is cumulative, so maybe we just need to be more patient?!
Thank you. | When was the food/insulin giving during that curve in january? | Translation? |
Roo is a 17-year-old f/s DSH cat who weighs 7.56#. She was diagnosed with Diabetes Mellitus 2 years ago. She has done very well on Glargine 1.25 U SQ BID and a mixture of Friskies and Calorie Control/Diabetic DS mixed. She is under the care of our local oncologist for an incompletely excised Vaccine Associated Sarcoma, which was excised/biopsied in December. She is tolerating the chemotherapy treatments well.
When she was in for her last chemo treatment 3 days ago, the bloodwork that day revealed her glucose was 103, so the oncologist suggested she follow up with me to see about adjusting her insulin dose. (Her other abnormalities included lipase 1740 (100 - 1400), amylase 1719 (500 - 1500), and BUN 41 (16 - 36). She was treated that day with Adriamycin and Cerenia and did very well.
She came in yesterday for a glucose curve. The owner gives her insulin and food around 7 am, and we started the glucose curve here at 8 am (1 hr post injection). Here are the numbers:
8 am (T = 1 hr) = 284
10:30 am (T = 3 1/2 hr) = 219
12:30 pm (T = 5 1/2 hr) = 266
2 pm (T = 7 hr) = 282
4 pm (T = 9 hrs) = 326
5:30 pm (T = 10 1/2 hrs) = 279
I was expecting some sort of Somogyi effect or something, either a very high or very low reading, but these readings are fairly steady, although a little higher than I would like. However, when we did her pre-op bloodwork in December, we did do a fructosamine which was 331, with 300 to 350 indicating excellent control.
Recent prior random glucose readings have been 320 (on 1/13), 365 (on 12/18). On the day of her surgery, since she was fasted, I had the owner reduce the insulin dose to 0.6 U, and readings were taken at 2 hrs post injection (232) and 4 hours post injection (143) and then she went home shortly thereafter and was fed and returned to her normal dosing schedule.
For a little bit of background info, she was initially placed on Glargine 1U SQ BID in July 2011. Glucose curve 2 weeks later:
T = 1 hr = 252
T = 3 hr = 325
T = 5 hr = 465
The curve was discontinued at that point, and owner was advised to increase her dose to 1.5 U SQ BID. Glucose curve one week later:
T = 1 hr = 185
T = 3 hr = 148
T = 5 hr = 240
T = 7 hr = 192
T = 9 hrs = 144
She did well at that dose, and her next glucose curve was done while she was boarding 3 months later. Her insulin injections were not given exactly 12 hours apart while she was here (11 hrs between am & pm dose and 13 hrs between pm and am dose).
T= 1/2 hr = 117
T = 2 1/2 hr = 109
T = 4 1/2 hr = 114
T = 7 1/2 hr = 213
T = 10 1/2 hr = 414
We did not change her dose while she was boarding because the schedule was not Q12 hours between injections, although this occasionally happens at home, too. When owner picked her up from boarding I told her I was concerned because the glucose went so high prior to the next dose, so I had her increase the insulin to 1.75 U SQ BID. (In retrospect, I think she may have been overswinging at the 1.5 U, so I proly should have reduced it to 1.25 U instead of increasing!) Her next glucose curve was done 2 weeks after dose change, again while boarding:
Pre-insulin glucose = 494
T = 1 hr = 487
T = 3 hrs = 487
T = 5 nrs = 395
T = 7 hrs = 255
T = 9 hrs = 121
T = 11 hrs = 152
I suspected Somogyi overswing, so we did not give her evening dose, and I reduced her dose to 1.25 U BID. Apparently she did well, because we did not see her again until she was here for vaccines 3 months later. My colleague did a mini panel which was unremarkable (glucose was 352, BUN was 45) and a fructosamine which was 412, with 400 - 450 indicating fair control. She was instructed to continue the 1.25 U SQ BID, and if any change in thirst, appetite, urination, etc was noted to have a glucose curve done.
I saw her 6 months later, and we did a senior panel, glucose = 224, BUN = 39, and her fructosamine was 343, with 300 - 350 indicating excellent control. We also did a UA (3+ glucose) and a c/s (neg). We continued the 1.25 U SQ BID, and no further diagnostics were pursued until we did her pre-op evaluation in December.
With regard to the current glucose curve, it looks like she is peaking at about 3 hours (as seen in majority of previous curves), but the level is not going down considerably. There are no spurious high readings or low to indicate an overswing, but I don't feel very comfortable with the idea of increasing the dose because I was certain she had overswing at 1.5 U.
What are your thoughts on this case? The owner is very attentive and says Roo is doing great at home!
Thanks in advance for your help.
Barb
Waterford, MI
LSU SVM 1996 | How often is she to get chemo? | Makes sense? |
Roo is a 17-year-old f/s DSH cat who weighs 7.56#. She was diagnosed with Diabetes Mellitus 2 years ago. She has done very well on Glargine 1.25 U SQ BID and a mixture of Friskies and Calorie Control/Diabetic DS mixed. She is under the care of our local oncologist for an incompletely excised Vaccine Associated Sarcoma, which was excised/biopsied in December. She is tolerating the chemotherapy treatments well.
When she was in for her last chemo treatment 3 days ago, the bloodwork that day revealed her glucose was 103, so the oncologist suggested she follow up with me to see about adjusting her insulin dose. (Her other abnormalities included lipase 1740 (100 - 1400), amylase 1719 (500 - 1500), and BUN 41 (16 - 36). She was treated that day with Adriamycin and Cerenia and did very well.
She came in yesterday for a glucose curve. The owner gives her insulin and food around 7 am, and we started the glucose curve here at 8 am (1 hr post injection). Here are the numbers:
8 am (T = 1 hr) = 284
10:30 am (T = 3 1/2 hr) = 219
12:30 pm (T = 5 1/2 hr) = 266
2 pm (T = 7 hr) = 282
4 pm (T = 9 hrs) = 326
5:30 pm (T = 10 1/2 hrs) = 279
I was expecting some sort of Somogyi effect or something, either a very high or very low reading, but these readings are fairly steady, although a little higher than I would like. However, when we did her pre-op bloodwork in December, we did do a fructosamine which was 331, with 300 to 350 indicating excellent control.
Recent prior random glucose readings have been 320 (on 1/13), 365 (on 12/18). On the day of her surgery, since she was fasted, I had the owner reduce the insulin dose to 0.6 U, and readings were taken at 2 hrs post injection (232) and 4 hours post injection (143) and then she went home shortly thereafter and was fed and returned to her normal dosing schedule.
For a little bit of background info, she was initially placed on Glargine 1U SQ BID in July 2011. Glucose curve 2 weeks later:
T = 1 hr = 252
T = 3 hr = 325
T = 5 hr = 465
The curve was discontinued at that point, and owner was advised to increase her dose to 1.5 U SQ BID. Glucose curve one week later:
T = 1 hr = 185
T = 3 hr = 148
T = 5 hr = 240
T = 7 hr = 192
T = 9 hrs = 144
She did well at that dose, and her next glucose curve was done while she was boarding 3 months later. Her insulin injections were not given exactly 12 hours apart while she was here (11 hrs between am & pm dose and 13 hrs between pm and am dose).
T= 1/2 hr = 117
T = 2 1/2 hr = 109
T = 4 1/2 hr = 114
T = 7 1/2 hr = 213
T = 10 1/2 hr = 414
We did not change her dose while she was boarding because the schedule was not Q12 hours between injections, although this occasionally happens at home, too. When owner picked her up from boarding I told her I was concerned because the glucose went so high prior to the next dose, so I had her increase the insulin to 1.75 U SQ BID. (In retrospect, I think she may have been overswinging at the 1.5 U, so I proly should have reduced it to 1.25 U instead of increasing!) Her next glucose curve was done 2 weeks after dose change, again while boarding:
Pre-insulin glucose = 494
T = 1 hr = 487
T = 3 hrs = 487
T = 5 nrs = 395
T = 7 hrs = 255
T = 9 hrs = 121
T = 11 hrs = 152
I suspected Somogyi overswing, so we did not give her evening dose, and I reduced her dose to 1.25 U BID. Apparently she did well, because we did not see her again until she was here for vaccines 3 months later. My colleague did a mini panel which was unremarkable (glucose was 352, BUN was 45) and a fructosamine which was 412, with 400 - 450 indicating fair control. She was instructed to continue the 1.25 U SQ BID, and if any change in thirst, appetite, urination, etc was noted to have a glucose curve done.
I saw her 6 months later, and we did a senior panel, glucose = 224, BUN = 39, and her fructosamine was 343, with 300 - 350 indicating excellent control. We also did a UA (3+ glucose) and a c/s (neg). We continued the 1.25 U SQ BID, and no further diagnostics were pursued until we did her pre-op evaluation in December.
With regard to the current glucose curve, it looks like she is peaking at about 3 hours (as seen in majority of previous curves), but the level is not going down considerably. There are no spurious high readings or low to indicate an overswing, but I don't feel very comfortable with the idea of increasing the dose because I was certain she had overswing at 1.5 U.
What are your thoughts on this case? The owner is very attentive and says Roo is doing great at home!
Thanks in advance for your help.
Barb
Waterford, MI
LSU SVM 1996 | How is the owner giving 1.25u? | Are there any neuro deficits (esp hopping, may be more sensitive to picking up subtle long track effects by loss of postural responses)? |
Hello there,
Looking for input on this case.
12 year old 8.6 kg F/S Border Terrier presented to my colleague Feb. 6th for PU/PD of 2-3 weeks duration
History:
-- Owner had recently started healthymouth water additive a few weeks prior to the CS's developing.
-- Other older dog in the house was recently diagnosed with Cushings.
-- She had a COHAT performed in November and one premolar was removed.
-- She has had 5 litters of puppies in her lifetime but is now spayed. one of the puppies in one of these litters was diagnosed with a liver shunt (unsure what type)
-- no vomiting but has had some soft tarry stools that have been gradually improving
-- she has had an intermittently decreased appetite over the past few weeks
PE at the time was WNL.
Bloodworks was done and is listed below:
Hematology
WBC 9.29 X10E9/L 4.5-13.0
RBC 7.21 X10E12/L 5.5 - 8.90
HGB 170.0 g/L 145-204
HCT 0.501 L\L 0.42-0.62
MCV 69.4 fL 63 - 77
MCH 23.5 pg 22 - 25.0
MCHC 339 g/L 320-360
RDW 15.5 % 13-18
Platelet count 350 X10E9/L 160 - 400
Differential: % ABS
Neutrophils 74 6.87 X10E9/L 2.70-8.50
Lymphocytes 17 1.58 X10E9/L 0.90-4.00
Monocytes 6 0.56 X10E9/L 0.0 - 0.98
Eosinophils 3 0.28 X10E9/L 0.0 - 1.231
RBC Morph See Below
COMMENTS: Platelet numbers are adequate .RBC morphology is normal for species .
Small Animal Chemistry Profile
Glucose, Serum 5.8 mmol/L 3.0 - 6.6
BUN 3.9 mmol/L 2.7-9.8
Creatinine 110.6 umol/L 60-138
BUN/Creatinine Ratio 35
Phosphorus 1.26 mmol/L 0.74-2.00
Calcium 2.50 mmol/L 2.03-2.80
Sodium 144 mmol/L 141-150
Potassium 4.5 mmol/L 4.0 - 5.4
Na/K Ratio 32
Total Protein 68 g/L 56-73
***Albumin 29.7 L g/L 30-40
Globulin 38 g/L 22-38
Albumin/Globulin Ratio 0.8 L 0.9-1.7
Bilirubin, Total 2 umol/L 0-7
***ALP 131 H U/L 21-122
ALT 54 U/L 0 -113
GGT 10 U/L 1-18
Chloride 109 mmol/L 107-115
Carbon Dioxide 23.4 mmol/L 18-26
Anion Gap 16 13-23
CPK 147 U/L 63-435
Osm, Calc 286 281-300
Cholesterol 6.8 mmol/L 3.70-9.30
Amylase 1361 U/L 337-1423
Lipase 497 U/L 80-750
Tetraiodothyronine 27.9 nmol/L 13-44
***USG = 1.007 (full UA not done)
Abnormalities noted: mildly elevated ALP, mild hypoalbuminemia and isosthenuria
I then saw the dog on recheck on Feb. 15th as per my colleagues recommendations.
Again, NSF on PE.
I did a bladder US - no masses or calculi noted. Urine was collected for full UA and culture via cystocentesis.
UA/culture results:
Urinalysis
UR. COLLECTION Cystocentesis
Color Pale
Appearance Clear
Sp Gravity 1.009
Urine pH 6
Protein Negative g/L
Glucose Negative mmol/L
Ketone Negative mmol/L
Bili Negative
Blood Negative
Urobilinogen Normal
RBC Negative
WBC Negative
Bacteria Negative
Crystal Amount Negative
Microbiology
1 Source URINE, CYSTO/CATH
Organism No growth on plates in 2 days
Assessment -- NO UTI, NSF ON UA OTHER THAN ISOSTHENURIA
At this point I recommended measuring water consumption over three separate 24 hour periods and collecting three first am urine samples for USG quantification. Urinary incontinence was now being reported at home but appetite/energy level remained normal.
Average water consumption per day = 1125 ml/d (~130 ml/kg/d)
USG three first am samples = 1.010, 1.010, 1.007
So, since the PU/PD was confirmed and still isosthenuric, I recommended an abdominal US and bile acid panel.
The US was done by a colleague in my clinic. US report as follows:
Liver: homogeneous echogenicity of parenchyma. THE LIVER APPEARS SMALL (but would rec. rads to confirm). THE PARENCHYMA IS ISOECHOIC TO THE SPLEEN. no signs of vascular abnormalities or hepatic congestion.
Gallbladder: The GB was normal with a normal wall thickness. There is a SMALL AMT OF SLUDGE PRESENT.
Kidneys: The kidneys are normal in size and shape. The capsules were smooth with no irregularities. The basic architecture was in tact with good contrast between the cortex and the medulla. The echogenicity was normal. THERE IS A 1.2 CM DIAMTER CYST IN THE CRANIODORSAL PORTION OF THE RIGHT RENAL CORTEX. CALCULATED VOLUME OF THIS CYST IS ABOUT 0.77 ml.
Adrenal glands: The adrenal glands were normal in size and shape. The echogenicity appeared normal.
Bladder: The bladder was seen to be full of urine, free of sediment or suspended material. The apex, mid-section and trigone showed no visible thickening or lesions. No calculi were seen.
GI tract: The GI tract and pancreatic region were WNL.
Lymph nodes: While the iliac lymph nodes appeared prominent, they measured WNL. Jejunal and portal LN's WNL.
Assessment:
Small liver (?)
Right renal cyst
Otherwise unremarkable study.
Pre and post bile acids were done:
Pre = 12.9 range 0-15
***Post = 33.7 range 0-22
ELEVATED POST BILE ACIDS. pathologist comments: values >25 suggest abnormal liver function and usually indicate hepatic pathology.
So, here are my questions:
1) I know that liver disease can cause PU/PD. Will we often see it so pronounced that we get isosthenuria as well?
2) Do you think it is likely that functional liver disease is causing the PU/PD in this case?
3) I was thinking next steps for liver work up should include USG FNA's or trucut biopsy of liver (after coag panel).
4) If liver biopsy/aspirates come back as normal or non-diagnostic, would you consider further work up for a possible liver shunt/MVD - ie nuclear portal scintigraphy or do you think that shunt is unlikely given that this dog is 12 years old?
5) Other differentials for PU/PD that I still have not ruled out include: Addison's, diabetes insipidus, leptospirosis (extremely rare in our area), paraneoplastic (extraabdominal mass), psychogenic, pericardial effusion, hypertension, primary non-medical polydipsia.
--> Do you think I should continue working up the liver before moving to other work up or should I move to other diagnostics at this point as well?
I was thinking other work up might include:
1) Chest rads (tumour hunt)
2) lepto testing (although very rare in our area)
3) modified water deprivation test and if urine still not concentrated, desmopressin trial
4) ACTH stim
Any thoughts/input or suggestions would be greatly appreciated.
Thanks,
~☼ | I assume that she has stopped giving this now? | Which brands do you carry (or can order)? |
Hello there,
Looking for input on this case.
12 year old 8.6 kg F/S Border Terrier presented to my colleague Feb. 6th for PU/PD of 2-3 weeks duration
History:
-- Owner had recently started healthymouth water additive a few weeks prior to the CS's developing.
-- Other older dog in the house was recently diagnosed with Cushings.
-- She had a COHAT performed in November and one premolar was removed.
-- She has had 5 litters of puppies in her lifetime but is now spayed. one of the puppies in one of these litters was diagnosed with a liver shunt (unsure what type)
-- no vomiting but has had some soft tarry stools that have been gradually improving
-- she has had an intermittently decreased appetite over the past few weeks
PE at the time was WNL.
Bloodworks was done and is listed below:
Hematology
WBC 9.29 X10E9/L 4.5-13.0
RBC 7.21 X10E12/L 5.5 - 8.90
HGB 170.0 g/L 145-204
HCT 0.501 L\L 0.42-0.62
MCV 69.4 fL 63 - 77
MCH 23.5 pg 22 - 25.0
MCHC 339 g/L 320-360
RDW 15.5 % 13-18
Platelet count 350 X10E9/L 160 - 400
Differential: % ABS
Neutrophils 74 6.87 X10E9/L 2.70-8.50
Lymphocytes 17 1.58 X10E9/L 0.90-4.00
Monocytes 6 0.56 X10E9/L 0.0 - 0.98
Eosinophils 3 0.28 X10E9/L 0.0 - 1.231
RBC Morph See Below
COMMENTS: Platelet numbers are adequate .RBC morphology is normal for species .
Small Animal Chemistry Profile
Glucose, Serum 5.8 mmol/L 3.0 - 6.6
BUN 3.9 mmol/L 2.7-9.8
Creatinine 110.6 umol/L 60-138
BUN/Creatinine Ratio 35
Phosphorus 1.26 mmol/L 0.74-2.00
Calcium 2.50 mmol/L 2.03-2.80
Sodium 144 mmol/L 141-150
Potassium 4.5 mmol/L 4.0 - 5.4
Na/K Ratio 32
Total Protein 68 g/L 56-73
***Albumin 29.7 L g/L 30-40
Globulin 38 g/L 22-38
Albumin/Globulin Ratio 0.8 L 0.9-1.7
Bilirubin, Total 2 umol/L 0-7
***ALP 131 H U/L 21-122
ALT 54 U/L 0 -113
GGT 10 U/L 1-18
Chloride 109 mmol/L 107-115
Carbon Dioxide 23.4 mmol/L 18-26
Anion Gap 16 13-23
CPK 147 U/L 63-435
Osm, Calc 286 281-300
Cholesterol 6.8 mmol/L 3.70-9.30
Amylase 1361 U/L 337-1423
Lipase 497 U/L 80-750
Tetraiodothyronine 27.9 nmol/L 13-44
***USG = 1.007 (full UA not done)
Abnormalities noted: mildly elevated ALP, mild hypoalbuminemia and isosthenuria
I then saw the dog on recheck on Feb. 15th as per my colleagues recommendations.
Again, NSF on PE.
I did a bladder US - no masses or calculi noted. Urine was collected for full UA and culture via cystocentesis.
UA/culture results:
Urinalysis
UR. COLLECTION Cystocentesis
Color Pale
Appearance Clear
Sp Gravity 1.009
Urine pH 6
Protein Negative g/L
Glucose Negative mmol/L
Ketone Negative mmol/L
Bili Negative
Blood Negative
Urobilinogen Normal
RBC Negative
WBC Negative
Bacteria Negative
Crystal Amount Negative
Microbiology
1 Source URINE, CYSTO/CATH
Organism No growth on plates in 2 days
Assessment -- NO UTI, NSF ON UA OTHER THAN ISOSTHENURIA
At this point I recommended measuring water consumption over three separate 24 hour periods and collecting three first am urine samples for USG quantification. Urinary incontinence was now being reported at home but appetite/energy level remained normal.
Average water consumption per day = 1125 ml/d (~130 ml/kg/d)
USG three first am samples = 1.010, 1.010, 1.007
So, since the PU/PD was confirmed and still isosthenuric, I recommended an abdominal US and bile acid panel.
The US was done by a colleague in my clinic. US report as follows:
Liver: homogeneous echogenicity of parenchyma. THE LIVER APPEARS SMALL (but would rec. rads to confirm). THE PARENCHYMA IS ISOECHOIC TO THE SPLEEN. no signs of vascular abnormalities or hepatic congestion.
Gallbladder: The GB was normal with a normal wall thickness. There is a SMALL AMT OF SLUDGE PRESENT.
Kidneys: The kidneys are normal in size and shape. The capsules were smooth with no irregularities. The basic architecture was in tact with good contrast between the cortex and the medulla. The echogenicity was normal. THERE IS A 1.2 CM DIAMTER CYST IN THE CRANIODORSAL PORTION OF THE RIGHT RENAL CORTEX. CALCULATED VOLUME OF THIS CYST IS ABOUT 0.77 ml.
Adrenal glands: The adrenal glands were normal in size and shape. The echogenicity appeared normal.
Bladder: The bladder was seen to be full of urine, free of sediment or suspended material. The apex, mid-section and trigone showed no visible thickening or lesions. No calculi were seen.
GI tract: The GI tract and pancreatic region were WNL.
Lymph nodes: While the iliac lymph nodes appeared prominent, they measured WNL. Jejunal and portal LN's WNL.
Assessment:
Small liver (?)
Right renal cyst
Otherwise unremarkable study.
Pre and post bile acids were done:
Pre = 12.9 range 0-15
***Post = 33.7 range 0-22
ELEVATED POST BILE ACIDS. pathologist comments: values >25 suggest abnormal liver function and usually indicate hepatic pathology.
So, here are my questions:
1) I know that liver disease can cause PU/PD. Will we often see it so pronounced that we get isosthenuria as well?
2) Do you think it is likely that functional liver disease is causing the PU/PD in this case?
3) I was thinking next steps for liver work up should include USG FNA's or trucut biopsy of liver (after coag panel).
4) If liver biopsy/aspirates come back as normal or non-diagnostic, would you consider further work up for a possible liver shunt/MVD - ie nuclear portal scintigraphy or do you think that shunt is unlikely given that this dog is 12 years old?
5) Other differentials for PU/PD that I still have not ruled out include: Addison's, diabetes insipidus, leptospirosis (extremely rare in our area), paraneoplastic (extraabdominal mass), psychogenic, pericardial effusion, hypertension, primary non-medical polydipsia.
--> Do you think I should continue working up the liver before moving to other work up or should I move to other diagnostics at this point as well?
I was thinking other work up might include:
1) Chest rads (tumour hunt)
2) lepto testing (although very rare in our area)
3) modified water deprivation test and if urine still not concentrated, desmopressin trial
4) ACTH stim
Any thoughts/input or suggestions would be greatly appreciated.
Thanks,
~☼ | Has there been any weight loss? | Were his hr, rr, bp, spo2 and temp normal? |
Hello there,
Looking for input on this case.
12 year old 8.6 kg F/S Border Terrier presented to my colleague Feb. 6th for PU/PD of 2-3 weeks duration
History:
-- Owner had recently started healthymouth water additive a few weeks prior to the CS's developing.
-- Other older dog in the house was recently diagnosed with Cushings.
-- She had a COHAT performed in November and one premolar was removed.
-- She has had 5 litters of puppies in her lifetime but is now spayed. one of the puppies in one of these litters was diagnosed with a liver shunt (unsure what type)
-- no vomiting but has had some soft tarry stools that have been gradually improving
-- she has had an intermittently decreased appetite over the past few weeks
PE at the time was WNL.
Bloodworks was done and is listed below:
Hematology
WBC 9.29 X10E9/L 4.5-13.0
RBC 7.21 X10E12/L 5.5 - 8.90
HGB 170.0 g/L 145-204
HCT 0.501 L\L 0.42-0.62
MCV 69.4 fL 63 - 77
MCH 23.5 pg 22 - 25.0
MCHC 339 g/L 320-360
RDW 15.5 % 13-18
Platelet count 350 X10E9/L 160 - 400
Differential: % ABS
Neutrophils 74 6.87 X10E9/L 2.70-8.50
Lymphocytes 17 1.58 X10E9/L 0.90-4.00
Monocytes 6 0.56 X10E9/L 0.0 - 0.98
Eosinophils 3 0.28 X10E9/L 0.0 - 1.231
RBC Morph See Below
COMMENTS: Platelet numbers are adequate .RBC morphology is normal for species .
Small Animal Chemistry Profile
Glucose, Serum 5.8 mmol/L 3.0 - 6.6
BUN 3.9 mmol/L 2.7-9.8
Creatinine 110.6 umol/L 60-138
BUN/Creatinine Ratio 35
Phosphorus 1.26 mmol/L 0.74-2.00
Calcium 2.50 mmol/L 2.03-2.80
Sodium 144 mmol/L 141-150
Potassium 4.5 mmol/L 4.0 - 5.4
Na/K Ratio 32
Total Protein 68 g/L 56-73
***Albumin 29.7 L g/L 30-40
Globulin 38 g/L 22-38
Albumin/Globulin Ratio 0.8 L 0.9-1.7
Bilirubin, Total 2 umol/L 0-7
***ALP 131 H U/L 21-122
ALT 54 U/L 0 -113
GGT 10 U/L 1-18
Chloride 109 mmol/L 107-115
Carbon Dioxide 23.4 mmol/L 18-26
Anion Gap 16 13-23
CPK 147 U/L 63-435
Osm, Calc 286 281-300
Cholesterol 6.8 mmol/L 3.70-9.30
Amylase 1361 U/L 337-1423
Lipase 497 U/L 80-750
Tetraiodothyronine 27.9 nmol/L 13-44
***USG = 1.007 (full UA not done)
Abnormalities noted: mildly elevated ALP, mild hypoalbuminemia and isosthenuria
I then saw the dog on recheck on Feb. 15th as per my colleagues recommendations.
Again, NSF on PE.
I did a bladder US - no masses or calculi noted. Urine was collected for full UA and culture via cystocentesis.
UA/culture results:
Urinalysis
UR. COLLECTION Cystocentesis
Color Pale
Appearance Clear
Sp Gravity 1.009
Urine pH 6
Protein Negative g/L
Glucose Negative mmol/L
Ketone Negative mmol/L
Bili Negative
Blood Negative
Urobilinogen Normal
RBC Negative
WBC Negative
Bacteria Negative
Crystal Amount Negative
Microbiology
1 Source URINE, CYSTO/CATH
Organism No growth on plates in 2 days
Assessment -- NO UTI, NSF ON UA OTHER THAN ISOSTHENURIA
At this point I recommended measuring water consumption over three separate 24 hour periods and collecting three first am urine samples for USG quantification. Urinary incontinence was now being reported at home but appetite/energy level remained normal.
Average water consumption per day = 1125 ml/d (~130 ml/kg/d)
USG three first am samples = 1.010, 1.010, 1.007
So, since the PU/PD was confirmed and still isosthenuric, I recommended an abdominal US and bile acid panel.
The US was done by a colleague in my clinic. US report as follows:
Liver: homogeneous echogenicity of parenchyma. THE LIVER APPEARS SMALL (but would rec. rads to confirm). THE PARENCHYMA IS ISOECHOIC TO THE SPLEEN. no signs of vascular abnormalities or hepatic congestion.
Gallbladder: The GB was normal with a normal wall thickness. There is a SMALL AMT OF SLUDGE PRESENT.
Kidneys: The kidneys are normal in size and shape. The capsules were smooth with no irregularities. The basic architecture was in tact with good contrast between the cortex and the medulla. The echogenicity was normal. THERE IS A 1.2 CM DIAMTER CYST IN THE CRANIODORSAL PORTION OF THE RIGHT RENAL CORTEX. CALCULATED VOLUME OF THIS CYST IS ABOUT 0.77 ml.
Adrenal glands: The adrenal glands were normal in size and shape. The echogenicity appeared normal.
Bladder: The bladder was seen to be full of urine, free of sediment or suspended material. The apex, mid-section and trigone showed no visible thickening or lesions. No calculi were seen.
GI tract: The GI tract and pancreatic region were WNL.
Lymph nodes: While the iliac lymph nodes appeared prominent, they measured WNL. Jejunal and portal LN's WNL.
Assessment:
Small liver (?)
Right renal cyst
Otherwise unremarkable study.
Pre and post bile acids were done:
Pre = 12.9 range 0-15
***Post = 33.7 range 0-22
ELEVATED POST BILE ACIDS. pathologist comments: values >25 suggest abnormal liver function and usually indicate hepatic pathology.
So, here are my questions:
1) I know that liver disease can cause PU/PD. Will we often see it so pronounced that we get isosthenuria as well?
2) Do you think it is likely that functional liver disease is causing the PU/PD in this case?
3) I was thinking next steps for liver work up should include USG FNA's or trucut biopsy of liver (after coag panel).
4) If liver biopsy/aspirates come back as normal or non-diagnostic, would you consider further work up for a possible liver shunt/MVD - ie nuclear portal scintigraphy or do you think that shunt is unlikely given that this dog is 12 years old?
5) Other differentials for PU/PD that I still have not ruled out include: Addison's, diabetes insipidus, leptospirosis (extremely rare in our area), paraneoplastic (extraabdominal mass), psychogenic, pericardial effusion, hypertension, primary non-medical polydipsia.
--> Do you think I should continue working up the liver before moving to other work up or should I move to other diagnostics at this point as well?
I was thinking other work up might include:
1) Chest rads (tumour hunt)
2) lepto testing (although very rare in our area)
3) modified water deprivation test and if urine still not concentrated, desmopressin trial
4) ACTH stim
Any thoughts/input or suggestions would be greatly appreciated.
Thanks,
~☼ | With decreased appetite and a recent history of abnormal stools do we need to look at the gi tract further? | If the owner approaches and pets him when this happens does he seem aware of her presence? |
A 20 year old, 5lb 10oz female spayed, DSH presented on Saturday with polyphagia, polyuria, polydypsia and wt loss. Physical exam revealed mild dehydration and muscle wasting. I thought I felt an enlarged thyroid gland. Cat senior screen (CBC, Chem, T4) was sent to Marshfield and came back today. The only abnormalities were BUN = 56 vs (16-36) and cholesterol = 330 vs (81-275). Thoughts on how to proceed with diagnostics?
☼ | What was the t4 level? | How far apart were the 2 most recent seizures? |
A 20 year old, 5lb 10oz female spayed, DSH presented on Saturday with polyphagia, polyuria, polydypsia and wt loss. Physical exam revealed mild dehydration and muscle wasting. I thought I felt an enlarged thyroid gland. Cat senior screen (CBC, Chem, T4) was sent to Marshfield and came back today. The only abnormalities were BUN = 56 vs (16-36) and cholesterol = 330 vs (81-275). Thoughts on how to proceed with diagnostics?
☼ | Was it by ria or ed? | How long after insulin was given? |
Hello,
This is my own personal cat. He now seems to be diabetic, and I am wondering what to do about his diet.
A quick recent history:
He is about 12, M(N), had PU Sx in 2011. Weighs about 13-14 pounds. FIV positive since 2008.
Became hyperT4 in 2010. Went from normal appetite to very ravenous overnight, and TT4 was about 5.0. Started on methimazole 2.5 mg PO BID.
Summer of 2012 I switched him to dry y/d. Another vet in the practice likes it so I figured I'd give it a try. (Note...the free T4 from 2011 was ordered by another vet...I never diagnosed him with a FT4 or monitor him with it, so the >100 I attribute to nonthyroidal illness?)
Last fall I ran a mini panel and his BG was 248, whereas it had previously been in the 90-100 range. However, there was no glucose in the urine and fructosamine was OK so I didn't do anything.
On his latest bloodwork his BG was 301 and 1+ glucose in the urine. He is not clinical, ie no PU/PD, etc.
I am thinking of just getting him back on methimazole and switching to a low carb, canned diet. Canned y/d has 9.1% carbs. I know that y/d is not looked upon too favorably here, but does anyone think just switching to canned y/d would be OK. I am also planning on starting Lantus 1 U BID.
Should I just go back to a regular/OTC canned diet? At least his kidneys look good, but he needs to have a luxated lens removed also. Dr. pets...they're great!
Thanks,
☼ | My question is, the 263 fructosamine? | The owner can accurately measure and then inject the insulin? |
Hello,
This is my own personal cat. He now seems to be diabetic, and I am wondering what to do about his diet.
A quick recent history:
He is about 12, M(N), had PU Sx in 2011. Weighs about 13-14 pounds. FIV positive since 2008.
Became hyperT4 in 2010. Went from normal appetite to very ravenous overnight, and TT4 was about 5.0. Started on methimazole 2.5 mg PO BID.
Summer of 2012 I switched him to dry y/d. Another vet in the practice likes it so I figured I'd give it a try. (Note...the free T4 from 2011 was ordered by another vet...I never diagnosed him with a FT4 or monitor him with it, so the >100 I attribute to nonthyroidal illness?)
Last fall I ran a mini panel and his BG was 248, whereas it had previously been in the 90-100 range. However, there was no glucose in the urine and fructosamine was OK so I didn't do anything.
On his latest bloodwork his BG was 301 and 1+ glucose in the urine. He is not clinical, ie no PU/PD, etc.
I am thinking of just getting him back on methimazole and switching to a low carb, canned diet. Canned y/d has 9.1% carbs. I know that y/d is not looked upon too favorably here, but does anyone think just switching to canned y/d would be OK. I am also planning on starting Lantus 1 U BID.
Should I just go back to a regular/OTC canned diet? At least his kidneys look good, but he needs to have a luxated lens removed also. Dr. pets...they're great!
Thanks,
☼ | Does this seem like a good plan? | So, does the dog have clinical signs suggesting the diabetes is out of control? |
Saw a 15YO NM DSH this morning that has been a stable diabetic for years. Older man doing the best he can with his care (definitely limited in many ways...very long story). I've been surprised he has done as well as he has for so long.
Anyway he came in emaciated (he collapsed on the floor Friday night and hadn't moved). Owner was syringe feeding meat baby food and continued to give him his insulin the whole weekend while he lay in the same place on the kitchen floor :-(
The cat was an emaciated extremely dehydrated skeleton. (He was fine 2 months ago at his last check-up)
It was really bizarre because lying still on his side in the r it simply appeared that one of his front legs was on completely backwards.
This is all so very, very sad as this man just didn't know any better and this cat was about all he had in this world.
Once he got here today the decision to euthanize was about immediate without much of an exam (money also a huge issue). After he died I looked better at his front leg. His scapula was completely flipped upside down against his body wall. In the right location...lateral surface now facing in and medial surface now facing out thus the backwards front leg.
One of the most bizarre things I've ever seen. I've heard of dislocating the scapula but how in the world did it get flipped upside down?
I loved this old guy and his crotchity old cat. For so many reasons this was all so sad :-( He was literally weeping in the room as he let go of his best friend.
Needed to share the weirdness and vent the sad some with this one...thanks, guys,
☼ | What!! i don't suppose you got a pic? | You noted that she is tiny - has she ever had a bile acids test? |
"ABC" is a 12yr old sfe Rat Terrier. She was dx with Diabetes Mellitus in Oct 2010. She was started on .25units/lb of NPH insulin BID. Her glucose curves were good until June 2012. Increased her insulin in June, July, November, Decemberof 2012 and Feb 2013. She is currently on .75 units/lb BID. The ACTH stim(Cortrosyn IV) on 2/23/12 was baseline 395 nmol/L(28-196) 1hr post 1,342 nmol/L and the 2hr post 370 nmol/L. I would think this is indicative of cushings syndrone. Below is the CBC/Panel/UA/T4 from 2/15/13. Urine culture was negative(cysto).
Tests Results Ref. Range Units Tests Results Ref. Range Units
Total Protein 6.8 5.0-7.4 g/dL
Albumin 3.7 2.7-4.4 g/dL
Globulin 3.1 1.6-3.6 g/dL
A/G Ratio 1.2 0.8-2.0 Ratio
AST (SGOT) 35 15-66 U/L
ALT (SGPT) 237 (HIGH) 12-118 U/L
Alk Phosphatase 446 (HIGH) 5-131 U/L
GGTP 30 (HIGH) 1-12 U/L
Result verified.
Total Bilirubin 0.1 0.1-0.3 mg/dL
Urea Nitrogen 11 6-31 mg/dL
Creatinine 0.4 (LOW) 0.5-1.6 mg/dL
BUN/Creatinine Ratio 28 (HIGH) 4-27 Ratio
Phosphorus 4.9 2.5-6.0 mg/dL
Glucose 326 (HIGH) 70-138 mg/dL
Calcium 10.5 8.9-11.4 mg/dL
Magnesium 1.5 1.5-2.5 mEq/L
Sodium 142 139-154 mEq/L
Potassium 5.0 3.6-5.5 mEq/L
Na/K Ratio 28
Chloride 99 (LOW) 102-120 mEq/L
Cholesterol 559 (HIGH) 92-324 mg/dL
Triglycerides 735 (HIGH) 29-291 mg/dL
Amylase 252 (LOW) 290-1125 U/L
Lipase 487 77-695 U/L
CPK 177 59-895 U/L
Comment
Magnesium may be falsely elevated due to a Hemolysis 3+, Lipemia 1+ and could be below the Normal Range.
WBC 7.5 4.0-15.5 103/µL
RBC 7.80 4.8-9.3 106/µL
Hemoglobin 17.9 12.1-20.3 g/dL
Hematocrit 55.0 36-60 %
MCV 71 58-79 fL
MCH 22.9 19-28 pg
MCHC 32.5 30-38 g/dL
Platelet Count 333 170-400 103/µL
Platelet EST Adequate Adequate
Differential Absolute %
Neutrophils 4875 65 2060-10600 /uL
Bands 0 0 0-300 /uL
Lymphocytes 1500 20 690-4500 /uL
Monocytes (HIGH) 975 13 0-840 /uL
Eosinophils 75 1 0-1200 /uL
Basophils 75 1 0-150 /uL
Test Requested Results Reference Range Units
TOTAL T4
T4 2.8 0.8-3.5 ug/dL
Note new Canine reference range
URINALYSIS
Collection Method
Not stated
Color Yellow
Appearance Cloudy *Clear
Specific Gravity 1.042 1.015-1.050
pH 6.5 5.5-7.0
Protein Trace Neg
Microalbuminuria testing is recommended (if sediment is inactive) to help determine the clinical significance of proteinuria.
Glucose 3+ (HIGH) Neg
Result verified.
Ketone Negative Neg
Bilirubin Negative Neg To 1+
Blood Negative Neg
WBC None 0-3 HPF
RBC None 0-3 HPF
Casts None Seen LPF
Amorphous Urate Crystals 4-10 HPF
Bacteria None Seen None HPF
Transitional Epithelia 0-1 0-1 HPF
My current plan is to start the Trilostane at 1 mg/kg BID and decrease the insulin dose about 50%. How long do we need to be on the Trilostane before repeating the ACTH Stim? Should the ACTH Stim be 3-4 hrs the morning Trilostane? Any other suggestions would be appreciated.
☼ | Was the latest labwork done after a 12 hour fast? | As far as glucose curves, would the client be able to get bg's in the home? |
"ABC" is a 12yr old sfe Rat Terrier. She was dx with Diabetes Mellitus in Oct 2010. She was started on .25units/lb of NPH insulin BID. Her glucose curves were good until June 2012. Increased her insulin in June, July, November, Decemberof 2012 and Feb 2013. She is currently on .75 units/lb BID. The ACTH stim(Cortrosyn IV) on 2/23/12 was baseline 395 nmol/L(28-196) 1hr post 1,342 nmol/L and the 2hr post 370 nmol/L. I would think this is indicative of cushings syndrone. Below is the CBC/Panel/UA/T4 from 2/15/13. Urine culture was negative(cysto).
Tests Results Ref. Range Units Tests Results Ref. Range Units
Total Protein 6.8 5.0-7.4 g/dL
Albumin 3.7 2.7-4.4 g/dL
Globulin 3.1 1.6-3.6 g/dL
A/G Ratio 1.2 0.8-2.0 Ratio
AST (SGOT) 35 15-66 U/L
ALT (SGPT) 237 (HIGH) 12-118 U/L
Alk Phosphatase 446 (HIGH) 5-131 U/L
GGTP 30 (HIGH) 1-12 U/L
Result verified.
Total Bilirubin 0.1 0.1-0.3 mg/dL
Urea Nitrogen 11 6-31 mg/dL
Creatinine 0.4 (LOW) 0.5-1.6 mg/dL
BUN/Creatinine Ratio 28 (HIGH) 4-27 Ratio
Phosphorus 4.9 2.5-6.0 mg/dL
Glucose 326 (HIGH) 70-138 mg/dL
Calcium 10.5 8.9-11.4 mg/dL
Magnesium 1.5 1.5-2.5 mEq/L
Sodium 142 139-154 mEq/L
Potassium 5.0 3.6-5.5 mEq/L
Na/K Ratio 28
Chloride 99 (LOW) 102-120 mEq/L
Cholesterol 559 (HIGH) 92-324 mg/dL
Triglycerides 735 (HIGH) 29-291 mg/dL
Amylase 252 (LOW) 290-1125 U/L
Lipase 487 77-695 U/L
CPK 177 59-895 U/L
Comment
Magnesium may be falsely elevated due to a Hemolysis 3+, Lipemia 1+ and could be below the Normal Range.
WBC 7.5 4.0-15.5 103/µL
RBC 7.80 4.8-9.3 106/µL
Hemoglobin 17.9 12.1-20.3 g/dL
Hematocrit 55.0 36-60 %
MCV 71 58-79 fL
MCH 22.9 19-28 pg
MCHC 32.5 30-38 g/dL
Platelet Count 333 170-400 103/µL
Platelet EST Adequate Adequate
Differential Absolute %
Neutrophils 4875 65 2060-10600 /uL
Bands 0 0 0-300 /uL
Lymphocytes 1500 20 690-4500 /uL
Monocytes (HIGH) 975 13 0-840 /uL
Eosinophils 75 1 0-1200 /uL
Basophils 75 1 0-150 /uL
Test Requested Results Reference Range Units
TOTAL T4
T4 2.8 0.8-3.5 ug/dL
Note new Canine reference range
URINALYSIS
Collection Method
Not stated
Color Yellow
Appearance Cloudy *Clear
Specific Gravity 1.042 1.015-1.050
pH 6.5 5.5-7.0
Protein Trace Neg
Microalbuminuria testing is recommended (if sediment is inactive) to help determine the clinical significance of proteinuria.
Glucose 3+ (HIGH) Neg
Result verified.
Ketone Negative Neg
Bilirubin Negative Neg To 1+
Blood Negative Neg
WBC None 0-3 HPF
RBC None 0-3 HPF
Casts None Seen LPF
Amorphous Urate Crystals 4-10 HPF
Bacteria None Seen None HPF
Transitional Epithelia 0-1 0-1 HPF
My current plan is to start the Trilostane at 1 mg/kg BID and decrease the insulin dose about 50%. How long do we need to be on the Trilostane before repeating the ACTH Stim? Should the ACTH Stim be 3-4 hrs the morning Trilostane? Any other suggestions would be appreciated.
☼ | Do you think this is possible? | Or? |
Hi All-
Looking for a little guidance on this one.
Signalment: 13 year old 60 pound lab mix FS.
History: Arthritic hips and carpi, currently takes Previcox 227mg tablet, 1/2 SID. Routine NSAID following bloodwork.
I inherited this case 2 months ago from one of the other doctors in our practice. The owner has multiple pets, including a diabetic cat, an asthmatic cat, and like 6 other cats.
The dog has been on Previcox since June 2012.her CBC/Chem/T4 and FT4 at that time were all normal except a Calcium of 13.0 (normal 8.9-11.4). The owner elected to recheck it in a few months. A chemistry panel from 8-10-2012 still had a high calcium (12.8) but otherwise WNL, and was on daily Previcox at this time. No reported problems.
The dog was kept on Previcox daily, but was lost to followup until last week. The dog was still BAR and reportedly doing well. This time I checked a CBC, Chem and UA. The CBC was normal. The chem had her calcium at 12.7, other values WNL. The urine had a Usg of 1.041, moderate WBC's and cocci and rods. I started her on Clavamox for the UTI. No crystalluria.
I discussed hypercalcemia with the owners, and they declined 3 view thoracic rads and an and u/s at this point, but did consent to an Ionized Calcium and PTH levels. Her ionized is high at 1.61 (1.24-1.43 mmol/L and her PTH was 2.40 (0.50-5.80 pmol/L.
So here are my questions.
1) I can't find any reason, btu the Previcox would not be causing this right? (owner asked)
2) Other than sending her for an ultrasound of the neck (as well as the abdomen and chest films) any other options here?
Thanks
/p
p / DVM, CCRP
drbrunke.wordpress.com | Was the phosphorus low? | Any known hx of head injury? |
Pearl is an 11 year old FS DSH. She is usually seen by another associate here. She has been diabetic for 2.5 years. Initially she was well controlled on ProZinc BID, but she gradually needed more insulin and has not had good control as far as pu/pd and urinary accidents. Last springt the other associate had this 10 lb cat on 11 units BID and her BG curve had peaks of over 400 and a nadir of 273. At that point the other dr. spoke with a local internist and the internist thought the cat most likely has acromegaly. The owner declined the IGF-1 test to comfirm this.
Other vet then tried glargine (we don't use this much at our clinic) and we have curved the cat---the last curve was done in December 2012--and increased the insulin. The last curve when the cat was on 18 units glargine BID had peaks of 435 and a nadir of 349.
We did not hear from the owner until she came in to see me for vacc today. The owner has been increasing the glargine on her own. The cats weight is up to 12.75 lb (from 10.5 in 12-12) and she said the urinary accidents are better but the cats urine spots are huge. The owner increased the insulin to 33 units BID on her own and does no home testing. No hypoglucemic episodes seen.
So, now I am going to try home testing for the owner. This is new to me, also. I have been reading some great tips on VIN about owner home testing.
Can have some tips about what would be some reasonable goal numbers for this cat:
I assume when the owners curves that she should take a pre-insulin reading, then every two hours like we do here? What are some reasonable curve numbers?
Glargine still okay for this possible acromegaly cat?
(BTW, multiple urine cultures have been done. Also, the cat is on DM dry).
Thanks,
☼ | Does the cat otherwise look normal or is she sort of scruffy looking? | How sure are you that this bg of 58 mg/dl was accurate e.g. was it on a glucometer, then checked on a chem analyzer? |
Hi - Kiley is an 8 yr old FS Queensland mix , weighs 37# and is a little overweight. She was diagnosed with diabetes elsewhere several years ago, and is new to our hospital. She's on NPH 14 U BID. They feed Iams ProHealth dry. She can't make it through the night without urinating - wakes the owner up 1-2 times every night. Appetite up and down. Blind from cataracts. She came in today or a glucose curve and I also started an in-house urine culture. She was fed at 7:30 and for some reason the owner waited until 8:30 to give the insulin - usually they give it right after she eats breakfast. Here are the bg's:
9:20 323
10:20 249
11:20 238
12:25 182
1:20 162
3:20 369
4:40 511
I'm kicking myself for not getting a 2:20 bg! Could it have gone low enough in that 2 hr window to have triggered a Somoygi effect? Or is the insulin just wearing off? The owners say Kiley is fairly quiet/sleeps a lot, but they haven't seen any obvious hypoglycemic events. She also had lipemic serum from a previous blood draw, and 9/12 had elevated triglycerides. They won't feed her Royal Canin Low-fat due to the cost, but will try to find a lower fat Iams.
Thanks for any advice. | If we try to interpret this curve, i'd suspect we'll be interpreting something that really isn't what happens at home....but if i had to guess, i'd suspect the bg's may go down too low in the afternoon (especially if the initial bg's in the am aren't really as high at 9:20 am as we measured on this curve e.g. if the insulin was given with the food, would it have controlled the initial high bg's so she'd go even lower in the afternoon? | Neuro exam? |
Hi - Kiley is an 8 yr old FS Queensland mix , weighs 37# and is a little overweight. She was diagnosed with diabetes elsewhere several years ago, and is new to our hospital. She's on NPH 14 U BID. They feed Iams ProHealth dry. She can't make it through the night without urinating - wakes the owner up 1-2 times every night. Appetite up and down. Blind from cataracts. She came in today or a glucose curve and I also started an in-house urine culture. She was fed at 7:30 and for some reason the owner waited until 8:30 to give the insulin - usually they give it right after she eats breakfast. Here are the bg's:
9:20 323
10:20 249
11:20 238
12:25 182
1:20 162
3:20 369
4:40 511
I'm kicking myself for not getting a 2:20 bg! Could it have gone low enough in that 2 hr window to have triggered a Somoygi effect? Or is the insulin just wearing off? The owners say Kiley is fairly quiet/sleeps a lot, but they haven't seen any obvious hypoglycemic events. She also had lipemic serum from a previous blood draw, and 9/12 had elevated triglycerides. They won't feed her Royal Canin Low-fat due to the cost, but will try to find a lower fat Iams.
Thanks for any advice. | Who knows? | He's on an all-canned diet that is low enough in carbs? |
"Molly" is a 22 pound female (S) schnauzer with high triglycerides. She has had this issue in the past, but we have been able to keep the triglycerides below 500 with just Royal Canin LF diet and omega 3's (at the standard dose for her weight of the "Welactin" supplement by Nutramax, the liquid version that you put on the food...not the capsules).
As an acute issue about 4 weeks ago, Mollly became PUPD with urine accidents in house. Thankfully she had not become diabetic. UA and Urine culture were negative. Abdominal ultrasound really didn't show anything specific. Lepto titers were negative. On CBC Chemistry, however, the ALT was in the 300 range, the Alkaline Phosphatase was in the 5000 range, and the GGT was slightly elevated (13). Urine bile acids was normal.
We moved forward with treatment for some sort of vague hepatopathy. We put her on a 2-week course of Amoxicillin and Baytril, along with an indefinite course of Denamarin.
Clinically she was much better. No more PUPD per owner, and no more accidents in house. When I rechecked her blood panel at about 10 days later, both the ALT and the ALP were starting to decrease and the ALT was almost normal.
At that time, the owner wanted to do 2 more weeks of antibiotic therapy "just in case." I refilled this and planned recheck CBC Chem for about 10 days later, while still on meds.
On the day that she was coming in for the recheck blood panel, the owner called to say that Molly was acutely blind. We saw her for PE, drew her blood panel, and she went to optho referral to have an electroretinogram etc.
Optho diagnosed her with SARD, idiopathic, and they don't think that it is linked to the lipids/triglycerides. We will be of course pursuing a diagnostic workup for Cushings soon but that for now is delayed. Internist feels that the stress of SARD etc would affect the LDDST so we will wait one month for Cushings screen.
So here are the recheck lab values this week (note this is while she is on the last couple of days of antibiotics):
The ALT is back up to 254
The Alkaline Phosphatase is now 8149!!!
GGTP is now 42
Mild hypercalcemia of 11.5
Cholesterol is now 627
Triglycerides is now 1047
...I found out later that the owner forgot to fast her for this sample.....
Aside from vision loss, which the patient is coping very well with....she seems to be doing fine at home per owner.
I'm thinking that this is a vacuolar hepatopathy that is secondary in response to the high triglycerides? Our approach now is to support the liver with Denamarin, but otherwise be more aggressive about the triglycerides.
Here is my plan, let me know what you think:
1- For further diagnostics this week, recheck a T4 (hasn't had this for a couple of months) and do a coagulation profile including d-dimers. In one month, do the low dose dexamethasone suppression test
2- Continue Denamarin
3- Continue Royal Canin LF diet only
4- Continue EPA/Omega 3's. If I read the amount of EPA that is in each "scoop" of Welactin, it seems to fit in the recommended per kg dosing for hyperlipidemia patients. Do you have thoughts on altering this?
5- Add in Niacin therapy. I don't have the chart with me at this time, but for dosing I recommended that the owner pick up the "no flush" or "slow release" product and I went by the dosing you suggest on your hyperlipidemia link article in associate database. Any thoughts? Any specific brand? There is quite a range for dosing on this. How high would you suggest for this case for this 22 pound dog?
6- Add in Gemfibrozil medication. Again, I started dosing on this according to what is suggested in your lipids article. There is quite a range on this as well and I've never used it before. I'm assuming it is ok to use BOTH this and niacin concurrently? It's true that there is a risk of forming choleliths right? Do you think that going with a low dose of 150 mg PO ONCE daily would be reasonable? I'm nervous about starting this medication but I feel that I have no choice.
Sorry for the long post. These are great clients and a great dog.
Thanks for your input. | Did you recheck those last values on a fasting sample since you said the patient wasn't fasted? | Vetsulin needs to be shaken vigorously the first time the bottle is opened, then shaken enough each time it's used to keep it looking continuously milky...is this being done? |
"Molly" is a 22 pound female (S) schnauzer with high triglycerides. She has had this issue in the past, but we have been able to keep the triglycerides below 500 with just Royal Canin LF diet and omega 3's (at the standard dose for her weight of the "Welactin" supplement by Nutramax, the liquid version that you put on the food...not the capsules).
As an acute issue about 4 weeks ago, Mollly became PUPD with urine accidents in house. Thankfully she had not become diabetic. UA and Urine culture were negative. Abdominal ultrasound really didn't show anything specific. Lepto titers were negative. On CBC Chemistry, however, the ALT was in the 300 range, the Alkaline Phosphatase was in the 5000 range, and the GGT was slightly elevated (13). Urine bile acids was normal.
We moved forward with treatment for some sort of vague hepatopathy. We put her on a 2-week course of Amoxicillin and Baytril, along with an indefinite course of Denamarin.
Clinically she was much better. No more PUPD per owner, and no more accidents in house. When I rechecked her blood panel at about 10 days later, both the ALT and the ALP were starting to decrease and the ALT was almost normal.
At that time, the owner wanted to do 2 more weeks of antibiotic therapy "just in case." I refilled this and planned recheck CBC Chem for about 10 days later, while still on meds.
On the day that she was coming in for the recheck blood panel, the owner called to say that Molly was acutely blind. We saw her for PE, drew her blood panel, and she went to optho referral to have an electroretinogram etc.
Optho diagnosed her with SARD, idiopathic, and they don't think that it is linked to the lipids/triglycerides. We will be of course pursuing a diagnostic workup for Cushings soon but that for now is delayed. Internist feels that the stress of SARD etc would affect the LDDST so we will wait one month for Cushings screen.
So here are the recheck lab values this week (note this is while she is on the last couple of days of antibiotics):
The ALT is back up to 254
The Alkaline Phosphatase is now 8149!!!
GGTP is now 42
Mild hypercalcemia of 11.5
Cholesterol is now 627
Triglycerides is now 1047
...I found out later that the owner forgot to fast her for this sample.....
Aside from vision loss, which the patient is coping very well with....she seems to be doing fine at home per owner.
I'm thinking that this is a vacuolar hepatopathy that is secondary in response to the high triglycerides? Our approach now is to support the liver with Denamarin, but otherwise be more aggressive about the triglycerides.
Here is my plan, let me know what you think:
1- For further diagnostics this week, recheck a T4 (hasn't had this for a couple of months) and do a coagulation profile including d-dimers. In one month, do the low dose dexamethasone suppression test
2- Continue Denamarin
3- Continue Royal Canin LF diet only
4- Continue EPA/Omega 3's. If I read the amount of EPA that is in each "scoop" of Welactin, it seems to fit in the recommended per kg dosing for hyperlipidemia patients. Do you have thoughts on altering this?
5- Add in Niacin therapy. I don't have the chart with me at this time, but for dosing I recommended that the owner pick up the "no flush" or "slow release" product and I went by the dosing you suggest on your hyperlipidemia link article in associate database. Any thoughts? Any specific brand? There is quite a range for dosing on this. How high would you suggest for this case for this 22 pound dog?
6- Add in Gemfibrozil medication. Again, I started dosing on this according to what is suggested in your lipids article. There is quite a range on this as well and I've never used it before. I'm assuming it is ok to use BOTH this and niacin concurrently? It's true that there is a risk of forming choleliths right? Do you think that going with a low dose of 150 mg PO ONCE daily would be reasonable? I'm nervous about starting this medication but I feel that I have no choice.
Sorry for the long post. These are great clients and a great dog.
Thanks for your input. | Is there a reason for coag profile? | Are these intended to be fed raw? |
Can I put in a request for Dr to respond about this kitty?
Summary “Davis” Reed 7 yr old DSH orange MN tabby feline 2-26-13
Hisotry: Diagnosed feline asthma 2009
Management asthma terbutaline 2.5mg ¼ tab BID and Prednisolone 5mg EOD
Owner reported not giving any meds as of Oct 2012 moved to new house and tapered and discontinued meds without further signs.
Oct 2012 losing wt down to 9# 3oz from 13# 12.5oz in May 2012
PE left kidney feels larger, non painful, symmetrical compared to right
No murmur, thyroid not palpable, flea dirt present
CBC WBC 9400 few stim lymphs present Hct 36.1
Chem Glu 445
BUN 29 Creat 0.9 Cl 106 ALT 76 Chol 202 T4 0.6
UA Glucose 4+ Ketones neg SG 1.050
Urine culture negative
Started on Glargine insulin 2 units BID (0.5U/kg) 10-12-2012
Start on Purina DM diet
10-22-12 8# 14oz
Glucose curve Insulin given 5:15 am
Glu 7:30 = 402 9:30=412 11:30=593
Eating well, drinking less
Increased glargine to 3 units BID
12-7-12 12# 4oz Insulin 3 units 6:15 am
BG 8:15=392 10:15=504 12:00=417 2:00 =526
Increased glargine to 4 units BID
Feeding Hill’s m/d
1-4-13 12# 5oz
Glargine 7 am
BG 9:00=444 11:00=453 1:30=491 3:25=550
Increased glargine to 5 units BID
1-18-13
13# 4oz
BG 8:30=404 10:30=472 12:20=461 2:20=481 4;20=568
Increased to 6 units BID
2-1-12 13# 6oz
BG 8:14=407 10:15=480 12:15=574 2:15=495 4:15=482
New bottle of Lantus/Glargine
Suspecting Acromegaly
IGF-1 sent to MSU and result is 225 (12-92)
Researching on VIN
Never diagnosed or knowingly managed cat like this before.
Do we just keep increasing the insulin dose and by how much?
Understandably the owner is getting frustrated.
We have talked about doing curves at home and she is unable.
Davis can be fractious after a few pokes. He’s not too bad, just tired of the whole thing.
I would appreciate any help you can lend!
Thank you,
☼ | Does the cat look acromegalic? | Are you absolutely sure that the owner ever gave the methimazole during the first year and 8 months? |
Can I put in a request for Dr to respond about this kitty?
Summary “Davis” Reed 7 yr old DSH orange MN tabby feline 2-26-13
Hisotry: Diagnosed feline asthma 2009
Management asthma terbutaline 2.5mg ¼ tab BID and Prednisolone 5mg EOD
Owner reported not giving any meds as of Oct 2012 moved to new house and tapered and discontinued meds without further signs.
Oct 2012 losing wt down to 9# 3oz from 13# 12.5oz in May 2012
PE left kidney feels larger, non painful, symmetrical compared to right
No murmur, thyroid not palpable, flea dirt present
CBC WBC 9400 few stim lymphs present Hct 36.1
Chem Glu 445
BUN 29 Creat 0.9 Cl 106 ALT 76 Chol 202 T4 0.6
UA Glucose 4+ Ketones neg SG 1.050
Urine culture negative
Started on Glargine insulin 2 units BID (0.5U/kg) 10-12-2012
Start on Purina DM diet
10-22-12 8# 14oz
Glucose curve Insulin given 5:15 am
Glu 7:30 = 402 9:30=412 11:30=593
Eating well, drinking less
Increased glargine to 3 units BID
12-7-12 12# 4oz Insulin 3 units 6:15 am
BG 8:15=392 10:15=504 12:00=417 2:00 =526
Increased glargine to 4 units BID
Feeding Hill’s m/d
1-4-13 12# 5oz
Glargine 7 am
BG 9:00=444 11:00=453 1:30=491 3:25=550
Increased glargine to 5 units BID
1-18-13
13# 4oz
BG 8:30=404 10:30=472 12:20=461 2:20=481 4;20=568
Increased to 6 units BID
2-1-12 13# 6oz
BG 8:14=407 10:15=480 12:15=574 2:15=495 4:15=482
New bottle of Lantus/Glargine
Suspecting Acromegaly
IGF-1 sent to MSU and result is 225 (12-92)
Researching on VIN
Never diagnosed or knowingly managed cat like this before.
Do we just keep increasing the insulin dose and by how much?
Understandably the owner is getting frustrated.
We have talked about doing curves at home and she is unable.
Davis can be fractious after a few pokes. He’s not too bad, just tired of the whole thing.
I would appreciate any help you can lend!
Thank you,
☼ | There can be organomegaly with this, including renomegaly, but not asymmetrical...do you think the left kidney is large or is the right kidney small? | Sor, forgot to ask my main question - since phenobarbital increases cytochrome p450 enzymes, will its administration also help increase insulin metabolism to eliminate the additional amount of insulin in this patient's body? |
I'm looking for some ade on how to proceed. We have a 12 year old MN beagle that has just entered into the maitn phase with Lysodren and is now presented with a blood sugar of over 30 and is now diabetic. I'm just wondering should we discontinue the lysodren and get regulated with insulin or continue with the lysodren - the acth stim test is normal 0 hr 80 nmol/L , and 1 hr 331 nmol/l, and 2 hour 292 nmol/l. What insulin would you recommend?
Thank you
☼ | Uh-oh.....how long ago was the cushing's diagnosed? | What was her t4? |
I'm looking for some ade on how to proceed. We have a 12 year old MN beagle that has just entered into the maitn phase with Lysodren and is now presented with a blood sugar of over 30 and is now diabetic. I'm just wondering should we discontinue the lysodren and get regulated with insulin or continue with the lysodren - the acth stim test is normal 0 hr 80 nmol/L , and 1 hr 331 nmol/l, and 2 hour 292 nmol/l. What insulin would you recommend?
Thank you
☼ | What were the test results and clinical signs? | The owner can accurately measure and then inject the insulin--she has u40 syringes? |
I have a 8 year old MN Dachshund who has recently been diagnosed with severe IBD and PLE (internal medicine specialist performed abd ultrasound and endoscopy and biopsies). He initially presented for intermittent discomfort which was finally localized as abdominal pain. He has a great body condition score and is otherwise very healthy. His bloodwork indicated hypoalbuminemia and decreased total protein, but he never presented with edema. He has a low grade heart murmur, but thoracic radiographs were unremarkable. His biopsies indicated moderate to severe lymphoplasmacytic and eosniophilic enteritis with lymphangiectasia in the duodenum and jejunum. His current medication regimen includes: Budesonide 1mg one tablet SID, Famotidine 10mg one tablet PO SID, Cyclosporine 50mg one tablet PO SID, Carafate 1g 1/2 tablet PO SID and he is on Royal Canin low fat diet. I understand prognosis will have much to do with how well he responds to treatment, but his owner asked about quality of life and prognosis. Any thoughts? Also, his owner described a strange side effect (?) that seemed to coincide with the introduction of Cyclosporine. For the past four days, the patient has demonstrated this side effect. He has a normal bowel movement and then comes inside and can't settle and seems uncomfortable. The owner wondered about cramping? He then has a few accidents of soft, but formed stool inside and after about 30 minutes is back to normal. I am going to consult with the internist who performed the abdominal study and endoscopy, but the owner wanted a 2nd opinion as well. Thanks so much!
Total protein 4.8 (5.0-7.4 g/dL)
Albumin 2.6 (2.7-4.4 g/dL)
AST 74 (15-66 U/L)
Calcium 8.0 (8.9-11.4)
The rest of the bloodwork and urinalysis was WNL and a UP:UC was performed that was norma--0.1. I am happy to include all values if you need them. | Does this only happen soon after the cya is given? | Absolutely sure she's spayed? |
I have a 12 year old terrier x neutered male diabetic that's has been on Humulin NPH N insulin for four weeks. He started at 5 units BID and now at 7 units BID. The owner does the glucose curves at home weekly on Saturdays and seems to be reasonably competent at it. The curves however seem very erratic. The results for February 23 were : 7 am. 5.9 nmol/l. Norm. 6.1-11.38
8am. 9.4
7units humulin NPH
9am. 17.1
11am. 13.8
1pm. 10.8
3pm. 12.4
5pm. 11.5
7pm. 20.9
7 units humulin nph N
9pm. 16.9
Feb 24. 7am. 7.4
Quincy is fed 1/2 cup WD dry plus 3 ounces of boiled boneless, skinless, chicken at 7.30 am and 5pm. He is a picky eater but this combination he will consistently eat. He also has a history of chronic pancreatitis. We seem to be getting large and rapid fluctuations in glucose levels. I have requested that the evening meal be moved back closer to the time of the evening insulin. I would appreciate any comments or suggestions on where to go from here to get Quincys levels a little less erratic. Thanks in advance | Has the owner's glucometer been checked for accuracy? | Which one? |
I have a 12 year old terrier x neutered male diabetic that's has been on Humulin NPH N insulin for four weeks. He started at 5 units BID and now at 7 units BID. The owner does the glucose curves at home weekly on Saturdays and seems to be reasonably competent at it. The curves however seem very erratic. The results for February 23 were : 7 am. 5.9 nmol/l. Norm. 6.1-11.38
8am. 9.4
7units humulin NPH
9am. 17.1
11am. 13.8
1pm. 10.8
3pm. 12.4
5pm. 11.5
7pm. 20.9
7 units humulin nph N
9pm. 16.9
Feb 24. 7am. 7.4
Quincy is fed 1/2 cup WD dry plus 3 ounces of boiled boneless, skinless, chicken at 7.30 am and 5pm. He is a picky eater but this combination he will consistently eat. He also has a history of chronic pancreatitis. We seem to be getting large and rapid fluctuations in glucose levels. I have requested that the evening meal be moved back closer to the time of the evening insulin. I would appreciate any comments or suggestions on where to go from here to get Quincys levels a little less erratic. Thanks in advance | E.g. has one curve been done in the hospital, so you can compare numbers on the owner's machine vs those on a machine in-house that you know to be accurate? | What's the current chem screen look like? |
I have a 12 year old terrier x neutered male diabetic that's has been on Humulin NPH N insulin for four weeks. He started at 5 units BID and now at 7 units BID. The owner does the glucose curves at home weekly on Saturdays and seems to be reasonably competent at it. The curves however seem very erratic. The results for February 23 were : 7 am. 5.9 nmol/l. Norm. 6.1-11.38
8am. 9.4
7units humulin NPH
9am. 17.1
11am. 13.8
1pm. 10.8
3pm. 12.4
5pm. 11.5
7pm. 20.9
7 units humulin nph N
9pm. 16.9
Feb 24. 7am. 7.4
Quincy is fed 1/2 cup WD dry plus 3 ounces of boiled boneless, skinless, chicken at 7.30 am and 5pm. He is a picky eater but this combination he will consistently eat. He also has a history of chronic pancreatitis. We seem to be getting large and rapid fluctuations in glucose levels. I have requested that the evening meal be moved back closer to the time of the evening insulin. I would appreciate any comments or suggestions on where to go from here to get Quincys levels a little less erratic. Thanks in advance | How much does he weigh? | Have you tried inhaled medications? |
Zeus is a 6 year old poodle mix MC, now ~18 lbs. He was diagnosed almost a year ago with diabetes.
He is on Humulin N. ~5 units BID, he eats W/D.
I am not convinced he was ever perfectly regulated before but now is having more issues.
I guess a few months ago his owners separated and he was left with "Dad" who is more relaxed with his injections and care.
I guess he was getting into the cat food, stealing Dad's food and wasn't always getting his injections on time.
Now, "Mom" has moved back in and is trying to get things back under control.
Zeus has lost 3 pounds, and has immature cataracts. His bloodwork, U/A and culture are neg. and normal. His fructosamine is 615 (poor regulation)
The have an alpha trak and did a curve for me:
8am :565 ate bfast gave 5 units
10am: 485
12pm 417
230 pm 290
430 pm 421
640pm 319
8pm 286 ate dinner gave 5 units.
He seems to be curving nicely except for that his numbers are too high, but then he starts to go down again at 10 hours?
I remember him doing this before when she sent me curves.
He had a history of 1-2 bouts of pancreatitis before developing diabetes.
I wouldsome input. Thanks -☼ | Do you have any previous curves? | How's his hct? |
Zeus is a 6 year old poodle mix MC, now ~18 lbs. He was diagnosed almost a year ago with diabetes.
He is on Humulin N. ~5 units BID, he eats W/D.
I am not convinced he was ever perfectly regulated before but now is having more issues.
I guess a few months ago his owners separated and he was left with "Dad" who is more relaxed with his injections and care.
I guess he was getting into the cat food, stealing Dad's food and wasn't always getting his injections on time.
Now, "Mom" has moved back in and is trying to get things back under control.
Zeus has lost 3 pounds, and has immature cataracts. His bloodwork, U/A and culture are neg. and normal. His fructosamine is 615 (poor regulation)
The have an alpha trak and did a curve for me:
8am :565 ate bfast gave 5 units
10am: 485
12pm 417
230 pm 290
430 pm 421
640pm 319
8pm 286 ate dinner gave 5 units.
He seems to be curving nicely except for that his numbers are too high, but then he starts to go down again at 10 hours?
I remember him doing this before when she sent me curves.
He had a history of 1-2 bouts of pancreatitis before developing diabetes.
I wouldsome input. Thanks -☼ | Just out of curiosity, where do they get their insulin from? | Abd us? |
Zeus is a 6 year old poodle mix MC, now ~18 lbs. He was diagnosed almost a year ago with diabetes.
He is on Humulin N. ~5 units BID, he eats W/D.
I am not convinced he was ever perfectly regulated before but now is having more issues.
I guess a few months ago his owners separated and he was left with "Dad" who is more relaxed with his injections and care.
I guess he was getting into the cat food, stealing Dad's food and wasn't always getting his injections on time.
Now, "Mom" has moved back in and is trying to get things back under control.
Zeus has lost 3 pounds, and has immature cataracts. His bloodwork, U/A and culture are neg. and normal. His fructosamine is 615 (poor regulation)
The have an alpha trak and did a curve for me:
8am :565 ate bfast gave 5 units
10am: 485
12pm 417
230 pm 290
430 pm 421
640pm 319
8pm 286 ate dinner gave 5 units.
He seems to be curving nicely except for that his numbers are too high, but then he starts to go down again at 10 hours?
I remember him doing this before when she sent me curves.
He had a history of 1-2 bouts of pancreatitis before developing diabetes.
I wouldsome input. Thanks -☼ | When was the last time he had a ua/culture and a cbc/biochemical profiloe? | Have you done a fecal? |
Just wondering if I am doing all I should be for this cat.
Dusty is an ~15yo, MN, DLH. Dx diabetic elsewhere 2 years ago was on 3U NPH BID. Started coming to me past October.
Have been trying to get his glucose regulated, doing curves, adjusting insulin.
Having problems with the cat vomiting. Had been ~ every 7 days, then owner pulls back on insulin... It has made trying to regulate tricky.
Cat was upped to 3.5 U bid on 2/4 owner was doing at home 12 hour curves and low was 301, high was 597.
2/26 Hx; cat has not been feeling well past 7-10 days Cries for food then only eats a few bites, vomiting sometimes 5 minutes after eating other times just phlegm. Has not been getting insulin consistently because of the vomiting. Appetite decreased by ~1/2 even before this.
PE: quiet, responsive, HR 132 reg rhythm, RR 30 normal auscultation,mm pink, crt 1 sec, BSC 2/5, mod tartar, gingivitis, oral cavity wnl, normal borborygmus and abdomenal palpation. No diarrhea(per owner).
did not eat this am, dehydrated ~7%
rbc 6.10
HCT 29.3 (30-45)L
HGB 10.5
MCV 48
MCH 17.3
MCHC 35.9
RDW 18.5%
%RETIC 0.3
WBC 5.29 (5.5-19.5)L
NEU 3.15
LYM 1.04
MONO 0.61
EOS 0.49
BASO 0.01
PLT 403
GLU 253 (71-159)H
BUN 19
CREA 1.8
BUN/CREA 11
PHOS 3.6
CA 9.6
TP 7.4
ALB 2.9
GLOB 4.5
ALT 34
ALKP 41
GGT 0
TBIL 0.4
CHOL 180
AMYL 1375
LIPA 717
Na 159
K 3.7
Na/K 43
Cl 120
Osm Calc 323
USG 1.047, glu 1000, RBC 70-75/hpf (cysyo), WBC 0-1/hpf,trace prot.
Urine culture/MIC pending
Ddx IBD, neoplasia, food sensitivity,cystitis?
sent cat home on SQ fluids, metoclopramide and carafate.
Of course I'm just now thinking should have done fPLI.
Have also been talking to owner about ultrasound, endoscopy and such. That is if the owner can afford.
Anything I've not thought of? | Is there any way the client can afford to switch to lantus for this ty? | How many calories/meal does she currently get? |
Just wondering if I am doing all I should be for this cat.
Dusty is an ~15yo, MN, DLH. Dx diabetic elsewhere 2 years ago was on 3U NPH BID. Started coming to me past October.
Have been trying to get his glucose regulated, doing curves, adjusting insulin.
Having problems with the cat vomiting. Had been ~ every 7 days, then owner pulls back on insulin... It has made trying to regulate tricky.
Cat was upped to 3.5 U bid on 2/4 owner was doing at home 12 hour curves and low was 301, high was 597.
2/26 Hx; cat has not been feeling well past 7-10 days Cries for food then only eats a few bites, vomiting sometimes 5 minutes after eating other times just phlegm. Has not been getting insulin consistently because of the vomiting. Appetite decreased by ~1/2 even before this.
PE: quiet, responsive, HR 132 reg rhythm, RR 30 normal auscultation,mm pink, crt 1 sec, BSC 2/5, mod tartar, gingivitis, oral cavity wnl, normal borborygmus and abdomenal palpation. No diarrhea(per owner).
did not eat this am, dehydrated ~7%
rbc 6.10
HCT 29.3 (30-45)L
HGB 10.5
MCV 48
MCH 17.3
MCHC 35.9
RDW 18.5%
%RETIC 0.3
WBC 5.29 (5.5-19.5)L
NEU 3.15
LYM 1.04
MONO 0.61
EOS 0.49
BASO 0.01
PLT 403
GLU 253 (71-159)H
BUN 19
CREA 1.8
BUN/CREA 11
PHOS 3.6
CA 9.6
TP 7.4
ALB 2.9
GLOB 4.5
ALT 34
ALKP 41
GGT 0
TBIL 0.4
CHOL 180
AMYL 1375
LIPA 717
Na 159
K 3.7
Na/K 43
Cl 120
Osm Calc 323
USG 1.047, glu 1000, RBC 70-75/hpf (cysyo), WBC 0-1/hpf,trace prot.
Urine culture/MIC pending
Ddx IBD, neoplasia, food sensitivity,cystitis?
sent cat home on SQ fluids, metoclopramide and carafate.
Of course I'm just now thinking should have done fPLI.
Have also been talking to owner about ultrasound, endoscopy and such. That is if the owner can afford.
Anything I've not thought of? | What diet is being fed? | Is the fundic exam normal? |
Hi,
Enzo is a 8 yo MC mainly indoor cat who presented to me yesterday for weight loss and poor appetite. 10 days ago, the owners returned from a week long vacation and found the cat looking thinner and scruffy. Since then, the owner (an MD!) reports having not seen the cat eat anything! Apparently the cat food is kept in the basement because the toddler will eat it otherwise, so it is possible that the cat is eating something. No PU/PD, mild lethargy. No vomit/diarrhea/cough/sneeze. One other cat in the home who seems well.
PE: the cat has lost a third of his weight since we last saw him 9 months ago! mild-moderate dehydration, moderate dental disease (only a few remaining teeth), unkept coat, normal heart and lung sounds, no pain/masses/organomegaly on abdominal palpation, mild generalized muscle loss. The rest of the PE was unremarkable.
The owner is tying my hands with running diagnositics but did let me run baseline labwork. She has declined imaging and fPLI testing.
U/A: hazy,dark yellow, glucose>1000, protein 100, pH6, specific gravity >1.060, 0-1 transistional cells, negative for: blood, bilirubin, ketones, RBC, WBC, casts, crystals, bacteria
urine culture is pending
CBC/Chem/T4 is attached below. BG=387.
I don't understand why this cat isn't eating, am I wrong to be worried about pancreatitis? Assuming that he is a diabetic (no PU/PD or polyphagia), why else would he not be eating, since he doesn't seem to be ketotic (unless we are in early DKA and the dipstick can't pick up the first type of ketone that develops - β-hydroxybutyratez?) or have hepatic lipidosis?
Last night I gave him SC fluids and force fed 10 ml DM (didn't want to cause vomiting after he hasn't eaten for so long). I doubt this owner will allow further testing or hospitalization.
Do we start insulin since he isn't eating - that scares me! Force feed and then give insulin? Just try force feeding DM for a week +/- SC fluids and then recheck BG/urinalysis?
Please help!
Thanks,
☼ | It'd perhaps be kinder just to euthanize (and i don't say that lightly), but really....she watched the cat not eat for a week before bringing him in, and then won't let him be hospitalized when he's a diabetic who isn't eating? | How stressed is she when the bg curves are being done? |
Hello,
Munchkin is a 10 year old DMH, male neutered cat who has been having diarrhea for the last 6 months. He has also had mild weight loss and inappropriate defecation. No significant vomiting, not PU/PD, and had a good appetite. The diarrhea has not been responsive to bland diet, courses of metronidazole, and FortiFlora but has been somewhat responsive to Depo-Medrol injections. Unfortunatley, the last Depo injection only gave him 2-3 weeks of relief. His caretaker can not medicate him at home easily and he lives with 8 other cats. A CBC/Profile/T4 performed on 11/19/2012 was unremarkable.
An ultrasonographer from outside of my clinic performed an abdominal ultrasound today (2/27/2013) and found small bowel IBD, supected chronic pancreatitis, and right adrenal hyperplasia (neoplasia?). The left adrenal gland could not be visualized. His blood pressure today was 125mm Hg. I started a hypoallergenic diet and gave a Convenia injection. I hope this will help with the pancreatitis and IBD.
My real question is about the enlarged right adrenal gland. Are my ruleouts hyperaldosteronism, hyperadrenocorticicism, hyperandrogenism, and neoplasia? Others? Does this have any connection to the other findings? How should I proceed working up this issue? Some endocrine panel to MSU? Exploratory surgery? Other?
Thank you for your time and assistance with Munchkin!
Sincerely,
☼ | What exactly was the measurement for the right adrenal? | Did you know i was in minnesota, or was that just coincidence? |
Hello,
Munchkin is a 10 year old DMH, male neutered cat who has been having diarrhea for the last 6 months. He has also had mild weight loss and inappropriate defecation. No significant vomiting, not PU/PD, and had a good appetite. The diarrhea has not been responsive to bland diet, courses of metronidazole, and FortiFlora but has been somewhat responsive to Depo-Medrol injections. Unfortunatley, the last Depo injection only gave him 2-3 weeks of relief. His caretaker can not medicate him at home easily and he lives with 8 other cats. A CBC/Profile/T4 performed on 11/19/2012 was unremarkable.
An ultrasonographer from outside of my clinic performed an abdominal ultrasound today (2/27/2013) and found small bowel IBD, supected chronic pancreatitis, and right adrenal hyperplasia (neoplasia?). The left adrenal gland could not be visualized. His blood pressure today was 125mm Hg. I started a hypoallergenic diet and gave a Convenia injection. I hope this will help with the pancreatitis and IBD.
My real question is about the enlarged right adrenal gland. Are my ruleouts hyperaldosteronism, hyperadrenocorticicism, hyperandrogenism, and neoplasia? Others? Does this have any connection to the other findings? How should I proceed working up this issue? Some endocrine panel to MSU? Exploratory surgery? Other?
Thank you for your time and assistance with Munchkin!
Sincerely,
☼ | It's unusual to not be able to find the left adrenal, as that's the one that's further out in the abdomen...was this a radiologist that did the study? | Is mr. blonde losing weight? |
I have a new patient who is a 12-year-old MN Ragdoll. His records arrived from the previous veterinarian with a hand-written statement on the front: "Ren Issues."
As I read through the records, I saw lots and lots of chem panels, CBCs, UAs, urine cultures...
Since 2005, the cat has had azotemia, with Creatinines running 2.6-3.3 during that time (except for 2010, where it was norm at 2.1). USGs in the 1.040's; ways 3+ protein, high MAs. Cultures negative, but appears to have been treated with antibiotics (Clavamox, Amoxi, Covenia) sever times. The previous vet put the cat on K/D and had the owner giving SQF at home a few days a week (looks like 150 mL 2-3 times weekly).
The owner reports that the cat used to vomit 3-4 times a week during this time, but was not PU/PD, had no weight loss.
The cat presented for severe dent disease and when we did pre-anesthetic blood work, the Cr was 6.2 (0.6-2.4) and the BUN was 100 (14-36). The owner states now that he is PU/PD, vomiting is decreased to 1-2 times weekly, and there is weight loss. He so has a very elevated Amylase of 4052 (100-1200), with a norm Lipase.
I'm planning on treating him as a CRF case, but I'm curious what may have caused such a long-standing azotemia without any clinic signs. I've attached his most recent labs.
Thanks for any insight, br/i
CBC
WBC 10.0 3.5-16.0 103/mL
RBC 5.74 5.92-9.93 106/mL LOW
Hemoglobin 9.2 9.3-15.9 g/dL LOW
Hematocrit 27.8 29-48 % LOW
MCV 48 37-61 fL
MCH 16.0 11-21 pg
MCHC 33.1 30-38 g/dL
Platelet Count 115 200-500 103/mL LOW
Platelet count reflects the minimum number due to platelet clumping.
Platelet EST Adequate Adequate
Differenti Absolute %
Neutrophils 8200 82 2500-8500 /uL
Bands 0 0 0-150 /uL
Lymphocytes 800 8 1200-8000 /uL LOW
Monocytes 400 4 0-600 /uL
Eosinophils 600 6 0-1000 /uL
Basophils 0 0 0-150 /uL
Superchem
Tot Protein 7.7 5.2-8.8 g/dL
Albumin 3.6 2.5-3.9 g/dL
Globulin 4.1 2.3-5.3 g/dL
A/G Ratio 0.9 0.35-1.5 Ratio
AST (SGOT) 32 10-100 U/L
ALT (SGPT) 57 10-100 U/L
Alk Phosphatase 13 6-102 U/L
GGTP 5 1-10 U/L
Tot Bilirubin 0.1 0.1-0.4 mg/dL
Urea Nitrogen 98 14-36 mg/dL HIGH
Creatinine 6.1 0.6-2.4 mg/dL HIGH
BUN/Creatinine Ratio 16 4-33 Ratio
Phosphorus 6.6 2.4-8.2 mg/dL
Glucose 88 64-170 mg/dL
Ccium 10.5 8.2-10.8 mg/dL
Magnesium 1.9 1.5-2.5 mEq/L
Sodium 152 145-158 mEq/L
Potassium 3.9 3.4-5.6 mEq/L
Na/K Ratio 39
Chloride 121 104-128 mEq/L
Cholesterol 207 75-220 mg/dL
Triglycerides 58 25-160 mg/dL
Amylase 4052 100-1200 U/L HIGH
Result verified.
Lipase 56 0-205 U/L
CPK 89 56-529 U/L
Tot T4
T4 1.0 0.8-4.0 ug/dL
Free T4 (Equilibrium Diysis)
Free T4 (Diysis) 15 10-50 pmol/L
- - Feline Free T4 by Equilibrium Diysis Interpretive Comment - -
FT4(ED) should ALWAYS be interpreted with a tot T4 concentration when evuating a cat for hyperthyroidism. Approximately 5 to 10 percent of euthyroid cats with nonthyroid illness will have elevated FT4(ED). An elevated FT4ED with a tot T4 greater than 2.5 ug/dL is supportive of hyperthyroidism. An elevated FT4ED with a tot T4 less than 2.5 ug/dL is most consistent with nonthyroid illness.
- - - - - - - - - - - - - - - - - - - - - - - -
Urinysis
Collection Method
Not stated
Color Light Yellow
Appearance Clear *Clear
Specific Gravity 1.007 1.015-1.060 LOW
pH 6.0 5.5-7.0
Protein 2+ Neg HIGH
Urine protein:creatinine ratio testing is recommended (if the sediment is inactive) to help determine the clinic significance of proteinuria.
Glucose Negative Neg
Ketone Negative Neg
Bilirubin Negative Neg
Blood Negative Neg
WBC 0-1 0-3 HPF
RBC None 0-3 HPF
Casts None Seen LPF
Crysts None Seen HPF
Bacteria None Seen None HPF
Epitheli Cells None Seen HPF
Urine Microbumin (Feline)
Microbuminuria >30 2.5 mg/dL HIGH
The MA is greater than 30 mg/dl indicating overt buminuria. A P:C
ratio suggested to quantify the proteinuria.
Microbuminuria (MA) usuly indicates compromise of the glomerular
barrier and is a significant finding when it is persistent (2 or more
positive results obtained 2 or more weeks apart). Persistent MA, in
the majority of pets, is due to ren injury secondary to other
systemic disease or primary ren disease. Systemic diseases
associated with persistent MA include inflammatory disease, chronic
infections, metabolic disease (e.g. hypertension, Cushing's Syndrome,
diabetes mellitus, hyperthyroidism) and neoplasia. Fse positive
results may occur with pyuria and gross hematuria.
Suggestions for evuating patients with microbuminuria:
1. Check for and treat underlying diseases indicated above.
2. Recheck MA in 2-4 weeks
3. In the absence of underlying disease, monitor for progression of
MA and development of ren failure | Did the proteinuria ever improve on antibiotics? | Or, does the owner want to learn to generate the curves at home? |
I have a new patient who is a 12-year-old MN Ragdoll. His records arrived from the previous veterinarian with a hand-written statement on the front: "Ren Issues."
As I read through the records, I saw lots and lots of chem panels, CBCs, UAs, urine cultures...
Since 2005, the cat has had azotemia, with Creatinines running 2.6-3.3 during that time (except for 2010, where it was norm at 2.1). USGs in the 1.040's; ways 3+ protein, high MAs. Cultures negative, but appears to have been treated with antibiotics (Clavamox, Amoxi, Covenia) sever times. The previous vet put the cat on K/D and had the owner giving SQF at home a few days a week (looks like 150 mL 2-3 times weekly).
The owner reports that the cat used to vomit 3-4 times a week during this time, but was not PU/PD, had no weight loss.
The cat presented for severe dent disease and when we did pre-anesthetic blood work, the Cr was 6.2 (0.6-2.4) and the BUN was 100 (14-36). The owner states now that he is PU/PD, vomiting is decreased to 1-2 times weekly, and there is weight loss. He so has a very elevated Amylase of 4052 (100-1200), with a norm Lipase.
I'm planning on treating him as a CRF case, but I'm curious what may have caused such a long-standing azotemia without any clinic signs. I've attached his most recent labs.
Thanks for any insight, br/i
CBC
WBC 10.0 3.5-16.0 103/mL
RBC 5.74 5.92-9.93 106/mL LOW
Hemoglobin 9.2 9.3-15.9 g/dL LOW
Hematocrit 27.8 29-48 % LOW
MCV 48 37-61 fL
MCH 16.0 11-21 pg
MCHC 33.1 30-38 g/dL
Platelet Count 115 200-500 103/mL LOW
Platelet count reflects the minimum number due to platelet clumping.
Platelet EST Adequate Adequate
Differenti Absolute %
Neutrophils 8200 82 2500-8500 /uL
Bands 0 0 0-150 /uL
Lymphocytes 800 8 1200-8000 /uL LOW
Monocytes 400 4 0-600 /uL
Eosinophils 600 6 0-1000 /uL
Basophils 0 0 0-150 /uL
Superchem
Tot Protein 7.7 5.2-8.8 g/dL
Albumin 3.6 2.5-3.9 g/dL
Globulin 4.1 2.3-5.3 g/dL
A/G Ratio 0.9 0.35-1.5 Ratio
AST (SGOT) 32 10-100 U/L
ALT (SGPT) 57 10-100 U/L
Alk Phosphatase 13 6-102 U/L
GGTP 5 1-10 U/L
Tot Bilirubin 0.1 0.1-0.4 mg/dL
Urea Nitrogen 98 14-36 mg/dL HIGH
Creatinine 6.1 0.6-2.4 mg/dL HIGH
BUN/Creatinine Ratio 16 4-33 Ratio
Phosphorus 6.6 2.4-8.2 mg/dL
Glucose 88 64-170 mg/dL
Ccium 10.5 8.2-10.8 mg/dL
Magnesium 1.9 1.5-2.5 mEq/L
Sodium 152 145-158 mEq/L
Potassium 3.9 3.4-5.6 mEq/L
Na/K Ratio 39
Chloride 121 104-128 mEq/L
Cholesterol 207 75-220 mg/dL
Triglycerides 58 25-160 mg/dL
Amylase 4052 100-1200 U/L HIGH
Result verified.
Lipase 56 0-205 U/L
CPK 89 56-529 U/L
Tot T4
T4 1.0 0.8-4.0 ug/dL
Free T4 (Equilibrium Diysis)
Free T4 (Diysis) 15 10-50 pmol/L
- - Feline Free T4 by Equilibrium Diysis Interpretive Comment - -
FT4(ED) should ALWAYS be interpreted with a tot T4 concentration when evuating a cat for hyperthyroidism. Approximately 5 to 10 percent of euthyroid cats with nonthyroid illness will have elevated FT4(ED). An elevated FT4ED with a tot T4 greater than 2.5 ug/dL is supportive of hyperthyroidism. An elevated FT4ED with a tot T4 less than 2.5 ug/dL is most consistent with nonthyroid illness.
- - - - - - - - - - - - - - - - - - - - - - - -
Urinysis
Collection Method
Not stated
Color Light Yellow
Appearance Clear *Clear
Specific Gravity 1.007 1.015-1.060 LOW
pH 6.0 5.5-7.0
Protein 2+ Neg HIGH
Urine protein:creatinine ratio testing is recommended (if the sediment is inactive) to help determine the clinic significance of proteinuria.
Glucose Negative Neg
Ketone Negative Neg
Bilirubin Negative Neg
Blood Negative Neg
WBC 0-1 0-3 HPF
RBC None 0-3 HPF
Casts None Seen LPF
Crysts None Seen HPF
Bacteria None Seen None HPF
Epitheli Cells None Seen HPF
Urine Microbumin (Feline)
Microbuminuria >30 2.5 mg/dL HIGH
The MA is greater than 30 mg/dl indicating overt buminuria. A P:C
ratio suggested to quantify the proteinuria.
Microbuminuria (MA) usuly indicates compromise of the glomerular
barrier and is a significant finding when it is persistent (2 or more
positive results obtained 2 or more weeks apart). Persistent MA, in
the majority of pets, is due to ren injury secondary to other
systemic disease or primary ren disease. Systemic diseases
associated with persistent MA include inflammatory disease, chronic
infections, metabolic disease (e.g. hypertension, Cushing's Syndrome,
diabetes mellitus, hyperthyroidism) and neoplasia. Fse positive
results may occur with pyuria and gross hematuria.
Suggestions for evuating patients with microbuminuria:
1. Check for and treat underlying diseases indicated above.
2. Recheck MA in 2-4 weeks
3. In the absence of underlying disease, monitor for progression of
MA and development of ren failure | Has a upc ever been done? | Can you post the full panel from this visit please? |
Chimmee, a ten year old F/S mixed large breed dog presented last week for a health certificate as the doctor's daughter was moving and she wanted to take the dog with her when she moved. Historically, the dog had been symptomatically t":"d85ecf57-c49c-4b2b-b999-4992e511053e","type":"diminutive_match"}ted for diarrhea in December 2012 with the doctor declining ANY Dx workup. The December visit was the first time we had ever seen this dog or client.
Upon on presentation last week, the diarrhea had resolved on the symptomatic t":"d85ecf57-c49c-4b2b-b999-4992e511053e","type":"diminutive_match"}tment of metronidazole. Physical exam findings included BCS=3/9, Grade II-III periodontal disease, and III/VI holosystolic murmur and again a diagnostic and t":"d85ecf57-c49c-4b2b-b999-4992e511053e","type":"diminutive_match"}tment plan was given but this time given to the daughter and she called the doctor-father who okayed the estimate.
A minimum data base of thoracic radiographs, CBC, superchemistry profile and UA were performed. Mild generalized cardiomegaly was noted on the thoracic radiographs. There was a moderate primarily neutrophilic leucocytois of 29,000 and an anemia with Hct of 28%. The ALT was 222, SAP was 369, and the total bilirubin was 0.5. There was a hyperamylasemia of 1,414. The Usg was 1.019 with a benign but 2+ proteinuria and 1+ bilirubinuria. Further diagnostics were offered and declined.
The bottom line is that the client requested, from my associate, that he write a prescription for euthanasia solution as he wanted to euthanize his dog at home. Of course, that request was not honored, and an estimate for euthanasia was given and the option was also given for the client to take the dog to the humane society for euthanasia.
Our office manager called to check on Chimmee and the doctor-client said he gave the dog alot of ium, took his daughter to the airport, and then came home and overdosed the dog using insulin.
He took the dog to our local emergency clinic for private cremation.
I am seriously considering writing a letter to the medical board about this doctor. I cannot imagine going to a doctor who would even do this. This particular doctor has been practicing the the same town as my veterinary hospital for many years.
I would like to get your input.
Thank you. | Since this is the ethics board however- is it unethical? | Nooooo snacks between meals? |
HELP!!! I have acquired a case that everyone else has seen! Georgi is an 8 yr DSH that has been diagnosed with IBD histologically ( I am still sorting out records and finding info - so not sure if this was biopsy or not yet). He has been to the vet school in our area and was worked up from Trichomonas and other infectious causes of diarrhea. He has had a GI panel from a previous vet too that was unremarkable. Diet has only been Royal Canin Rabbit dry for years. The diarrhea was unresponsive to Prednisolone even at 5 mg BID ( 8 LB cat). metronidazole, tylosin and Flortiflora at least that is what I am told. This has been going on since 2008!! Alsp history of UTIs, sneezing, congestion,
In June became diabetic. This was on the higher dose of Pred. Ultrasound revealed hepatitis and thickened pancreas ( supsect pancreatitis) but his fpli was normal at the time and no vomiting. He did have an increased WBC count though. He was started on Glargine at that time. His diabetes was difficult to control but then in December began to need less insulin. Had a bout of upper respiratory congestion and was started on Clavamox and the stools were better than usual ( not normal but some form).
Then the owner moved and he was got out and was lost for 2 weeks. When he returned, owner said stools were best they had ever been in past few years and he was normoglycemic...at least for 3 weeks.
This is where I get him. I saw him 1 week ago. He is having increased frequency of decfecation- 10-12 times the night before I saw him ( normal for him per owner is 5 times a day). The stool has mucus. He is eating normally. His blood glucose was increased at 469, fructosamine increased 506 and the WBC count increased at 20,000 ( mature neutrophils). Chemistry screen normal. UA normal except glucosuria. Loops of bowel are not thickened on exam. I suspect he is having a bout of pancreatitis causing the increased WBCs and diabetes again. However, he does not vomit and seems to eat fine. Started Glargine 1 unit BID, started back on Clavamox and started Metronidazole ( frequency of defecation was cut in half after one dose of Clavamox and Metro).
His diarrhea is that of large bowel but suspect there is small bowel component too with the likely pancreatitis. I really feel we need to explore diet for this cat more thoroughly. Any suggestions? Raw, canned ( not sure he is a fan). Ideally would like to start from scratch on this case but feel the owner has invested so much time and money already... I am considering Cerenia for the inflammation, offering US or exploratory ( would need endoscopy for the colon though), diet change with Fortiflora again.
Why is his diarrhea better on Clavamox? How likely is bacterial overgrowth?
Any suggestions would be appreciated. This is a wonderful owner and cat.
Sorry for long post, br/ | Has this cat lost weight as well? | I presume the dog's not diabetic? |
I'll cross-post to internal medicine, but I know this gets more views so I figured I'd start here :)
Sampson is an adopted MN cat (about 2.5 yrs old according to the rescue group, but I think closer to 7ish years old) with diabetes. Owners adopted him on Feb 2nd, brought him to us on Feb 5th, and at his first exam we noticed an open wound on his left forelimb (it had been repaired by the Humane Society but had dehisced and was infected at the time we saw him), heavy dental tartar & gingivitis, enlarged popliteal lymph nodes, and bilateral otitis. Started Clavamox for the wound.
The owners brought him back in on Feb 6th for a dental, and so that we could clean up his wound while under anesthesia. Preanesthetic bloodwork showed: glucose 679 (74-159), globulin 7.0 (2.8-5.1), TP 9.3 (5.7-8.9). Remainder of the bloodwork was wnl (WBC 15.6). I talked to the owner, he debated whether to continue with tx or return the cat to the Humane Society, and decided to go ahead with a serum protein electrophoresis and put the cat on m/d while awaiting results. No dental performed that day.
Serum protein electrophoresis showed polyclonal gammopathy more consistent with infection than neoplasia, so I advised the owner that was likely due to the wound +/- dental dz and he decided to go ahead with diabetes tx. Started Lantus at 1U BID on Feb 9th. By that time, the forelimb wound was healed and looking great.
Glucose curve from Feb 19th:
9:00 - 389
11:00 - 218
1:00 - 109
3:30 - 61
5:30 - 73
I suspected Somogyi effect, and had the owners decrease the Lantus to 1/2 unit BID.
Today he's back for a repeat glucose curve, plus a urine culture & MIC (I had waited to do that because of the Clavamox). He had his food & insulin at approx 7 am.
9:00 - 486
11:00 - HI
1:00 - HI
3:00 - HI
Thoughts? I'm hesitant to go back up to 1U BID because of that 61 we saw at the last curve.... Keep him at 1/2U until we get the urine culture back, and hope for an infection that would lead to the erratic results? Go ahead and clean his teeth, even with such lack of control, in the hopes that we'll be better able to control him when we calm down his mouth?
☼ | What diet is this kitty eating? | Does the owner feel comfortable that she is getting the sample quickly and as stress free as possible when testing bg at home? |
I'll cross-post to internal medicine, but I know this gets more views so I figured I'd start here :)
Sampson is an adopted MN cat (about 2.5 yrs old according to the rescue group, but I think closer to 7ish years old) with diabetes. Owners adopted him on Feb 2nd, brought him to us on Feb 5th, and at his first exam we noticed an open wound on his left forelimb (it had been repaired by the Humane Society but had dehisced and was infected at the time we saw him), heavy dental tartar & gingivitis, enlarged popliteal lymph nodes, and bilateral otitis. Started Clavamox for the wound.
The owners brought him back in on Feb 6th for a dental, and so that we could clean up his wound while under anesthesia. Preanesthetic bloodwork showed: glucose 679 (74-159), globulin 7.0 (2.8-5.1), TP 9.3 (5.7-8.9). Remainder of the bloodwork was wnl (WBC 15.6). I talked to the owner, he debated whether to continue with tx or return the cat to the Humane Society, and decided to go ahead with a serum protein electrophoresis and put the cat on m/d while awaiting results. No dental performed that day.
Serum protein electrophoresis showed polyclonal gammopathy more consistent with infection than neoplasia, so I advised the owner that was likely due to the wound +/- dental dz and he decided to go ahead with diabetes tx. Started Lantus at 1U BID on Feb 9th. By that time, the forelimb wound was healed and looking great.
Glucose curve from Feb 19th:
9:00 - 389
11:00 - 218
1:00 - 109
3:30 - 61
5:30 - 73
I suspected Somogyi effect, and had the owners decrease the Lantus to 1/2 unit BID.
Today he's back for a repeat glucose curve, plus a urine culture & MIC (I had waited to do that because of the Clavamox). He had his food & insulin at approx 7 am.
9:00 - 486
11:00 - HI
1:00 - HI
3:00 - HI
Thoughts? I'm hesitant to go back up to 1U BID because of that 61 we saw at the last curve.... Keep him at 1/2U until we get the urine culture back, and hope for an infection that would lead to the erratic results? Go ahead and clean his teeth, even with such lack of control, in the hopes that we'll be better able to control him when we calm down his mouth?
☼ | Most of us would recommend a canned, low-carb diet (one with seven percent or fewer carbs) from this list : http://www.catinfo.org/docs/foodchartpublic9-22-12.pdf is sampson obese/overweight? | Could her renal disease affect her tsh level and falsely raise it? |
I'll cross-post to internal medicine, but I know this gets more views so I figured I'd start here :)
Sampson is an adopted MN cat (about 2.5 yrs old according to the rescue group, but I think closer to 7ish years old) with diabetes. Owners adopted him on Feb 2nd, brought him to us on Feb 5th, and at his first exam we noticed an open wound on his left forelimb (it had been repaired by the Humane Society but had dehisced and was infected at the time we saw him), heavy dental tartar & gingivitis, enlarged popliteal lymph nodes, and bilateral otitis. Started Clavamox for the wound.
The owners brought him back in on Feb 6th for a dental, and so that we could clean up his wound while under anesthesia. Preanesthetic bloodwork showed: glucose 679 (74-159), globulin 7.0 (2.8-5.1), TP 9.3 (5.7-8.9). Remainder of the bloodwork was wnl (WBC 15.6). I talked to the owner, he debated whether to continue with tx or return the cat to the Humane Society, and decided to go ahead with a serum protein electrophoresis and put the cat on m/d while awaiting results. No dental performed that day.
Serum protein electrophoresis showed polyclonal gammopathy more consistent with infection than neoplasia, so I advised the owner that was likely due to the wound +/- dental dz and he decided to go ahead with diabetes tx. Started Lantus at 1U BID on Feb 9th. By that time, the forelimb wound was healed and looking great.
Glucose curve from Feb 19th:
9:00 - 389
11:00 - 218
1:00 - 109
3:30 - 61
5:30 - 73
I suspected Somogyi effect, and had the owners decrease the Lantus to 1/2 unit BID.
Today he's back for a repeat glucose curve, plus a urine culture & MIC (I had waited to do that because of the Clavamox). He had his food & insulin at approx 7 am.
9:00 - 486
11:00 - HI
1:00 - HI
3:00 - HI
Thoughts? I'm hesitant to go back up to 1U BID because of that 61 we saw at the last curve.... Keep him at 1/2U until we get the urine culture back, and hope for an infection that would lead to the erratic results? Go ahead and clean his teeth, even with such lack of control, in the hopes that we'll be better able to control him when we calm down his mouth?
☼ | Is he clinical for diabetes mellitus at this point in time? | So you applied a few drops of skin glue? |
Presented for 1st time with 9 yr old MN 10# westie from westie rescue group. On drive up here from Smithtown, Long Island? dog went into resp distress and was rushed to animal hospital down in westmoreland, ny? Stayed there for a few days. guess at the time dog was rescued from shelter down there dog had been bathed in peroxide and chlorohexidine?The vet at that time noted severe dental dz, 1/6 lf SHM and abdomen felt bloated, facial alopecia and pruritis. Bdwk was run then cbc/chem/t4 AND 4dx HWT.
I don't have the specifics all the faxed medical report says is elevated bun, trig's, neuts, wbcs and slightly low pcv. T4? HWT was neg. Dog was placed on baytril for a week 22mg sid. skin scrape was + for Sarcoptic mange and dog was given 1% ivermec injection. At hosp dog had diarrhea. dog given ace for excessive barking and anxiety. T=99.1 HR=120 RR=40.
1 wk later dog was given another dose of ivermec injection and was neg for sarcoptic but + for demodex. dog was sent home with goodwinol ointment and lyme sulfur dip.
Dog came in today to recheck skin for mites as many other dogs at foster home and because dog seemed weak couldn't walk. Although was walking around ok in exam room. On PE today here by me:
dog was barking and happy......but emaciated/cachexic with BCS=1-2/9!!!!!
normal temp=100.4, mm=pk/mm=2 sec/good femoral pulses
didn't seem ataxic , although hind legs seemed to high hitch? flip forward a little? CP intact all 4 feet. good anal tone. no head tilt etc. could right itself if crossed hind legs.
all foot pads and accessory carpal pads ulcerated
diffuse alopecia, esp around nose/face/feet
severe dental dz
panting, SHM 2-3/6 heard more on rt side to me, lungs sounded a little wheezy? no nasal discharge seen.
repeated skin scrape =neg from tail, feet, nose, top of head
disc w/O continuing tx for at least next 2-4 wk with oral ivomec and take off goodwinol and lyme sulfur dip. (Nervous though a little with this due to recent resp distress syndrome in past?but I thought Ivomec doses in oral syrup so little:1% ivomec into 108ml cherry syrup-day 1 50ug/kg
day 2-3 100ug
day 4-6 150 ug
day 7-9 200ug
day 10-16 300ug
day 17-45 400ug)
also continued dog on oral baytril 22mg sid x next 3 wk
upon PE dog seemed to have abdominal pain in cranial abdomen but couldn't really palpate anything specific. just felt bloated. dog looks like a goat! disc w/O I was more worried about something going on internally than just skin problem. O okayed repeated bdwk and x-rays.
bdwk:hct 30.5% (NL=37%)
WBC normal at 12.68
plt 1121(NH=500)
chem:Bun 31 (NH=27)
Cr wnl at 0.7
GGT=8(NH=7) and ALKP 657 (NH=212)--no one knows if he is PU/PD/PP?-cushings? emaciation/malnourished? bone?
On rectal exam dog does have a little soft stool with some blood tinge | Not sure why dog is so nasal congested? | What diet is he on? |
Presented for 1st time with 9 yr old MN 10# westie from westie rescue group. On drive up here from Smithtown, Long Island? dog went into resp distress and was rushed to animal hospital down in westmoreland, ny? Stayed there for a few days. guess at the time dog was rescued from shelter down there dog had been bathed in peroxide and chlorohexidine?The vet at that time noted severe dental dz, 1/6 lf SHM and abdomen felt bloated, facial alopecia and pruritis. Bdwk was run then cbc/chem/t4 AND 4dx HWT.
I don't have the specifics all the faxed medical report says is elevated bun, trig's, neuts, wbcs and slightly low pcv. T4? HWT was neg. Dog was placed on baytril for a week 22mg sid. skin scrape was + for Sarcoptic mange and dog was given 1% ivermec injection. At hosp dog had diarrhea. dog given ace for excessive barking and anxiety. T=99.1 HR=120 RR=40.
1 wk later dog was given another dose of ivermec injection and was neg for sarcoptic but + for demodex. dog was sent home with goodwinol ointment and lyme sulfur dip.
Dog came in today to recheck skin for mites as many other dogs at foster home and because dog seemed weak couldn't walk. Although was walking around ok in exam room. On PE today here by me:
dog was barking and happy......but emaciated/cachexic with BCS=1-2/9!!!!!
normal temp=100.4, mm=pk/mm=2 sec/good femoral pulses
didn't seem ataxic , although hind legs seemed to high hitch? flip forward a little? CP intact all 4 feet. good anal tone. no head tilt etc. could right itself if crossed hind legs.
all foot pads and accessory carpal pads ulcerated
diffuse alopecia, esp around nose/face/feet
severe dental dz
panting, SHM 2-3/6 heard more on rt side to me, lungs sounded a little wheezy? no nasal discharge seen.
repeated skin scrape =neg from tail, feet, nose, top of head
disc w/O continuing tx for at least next 2-4 wk with oral ivomec and take off goodwinol and lyme sulfur dip. (Nervous though a little with this due to recent resp distress syndrome in past?but I thought Ivomec doses in oral syrup so little:1% ivomec into 108ml cherry syrup-day 1 50ug/kg
day 2-3 100ug
day 4-6 150 ug
day 7-9 200ug
day 10-16 300ug
day 17-45 400ug)
also continued dog on oral baytril 22mg sid x next 3 wk
upon PE dog seemed to have abdominal pain in cranial abdomen but couldn't really palpate anything specific. just felt bloated. dog looks like a goat! disc w/O I was more worried about something going on internally than just skin problem. O okayed repeated bdwk and x-rays.
bdwk:hct 30.5% (NL=37%)
WBC normal at 12.68
plt 1121(NH=500)
chem:Bun 31 (NH=27)
Cr wnl at 0.7
GGT=8(NH=7) and ALKP 657 (NH=212)--no one knows if he is PU/PD/PP?-cushings? emaciation/malnourished? bone?
On rectal exam dog does have a little soft stool with some blood tinge | Stomach very full---perhaps reason for abdominal pain? | Was that last acth stim started 3-5 hours after the trilostane was given with food? |
Presented for 1st time with 9 yr old MN 10# westie from westie rescue group. On drive up here from Smithtown, Long Island? dog went into resp distress and was rushed to animal hospital down in westmoreland, ny? Stayed there for a few days. guess at the time dog was rescued from shelter down there dog had been bathed in peroxide and chlorohexidine?The vet at that time noted severe dental dz, 1/6 lf SHM and abdomen felt bloated, facial alopecia and pruritis. Bdwk was run then cbc/chem/t4 AND 4dx HWT.
I don't have the specifics all the faxed medical report says is elevated bun, trig's, neuts, wbcs and slightly low pcv. T4? HWT was neg. Dog was placed on baytril for a week 22mg sid. skin scrape was + for Sarcoptic mange and dog was given 1% ivermec injection. At hosp dog had diarrhea. dog given ace for excessive barking and anxiety. T=99.1 HR=120 RR=40.
1 wk later dog was given another dose of ivermec injection and was neg for sarcoptic but + for demodex. dog was sent home with goodwinol ointment and lyme sulfur dip.
Dog came in today to recheck skin for mites as many other dogs at foster home and because dog seemed weak couldn't walk. Although was walking around ok in exam room. On PE today here by me:
dog was barking and happy......but emaciated/cachexic with BCS=1-2/9!!!!!
normal temp=100.4, mm=pk/mm=2 sec/good femoral pulses
didn't seem ataxic , although hind legs seemed to high hitch? flip forward a little? CP intact all 4 feet. good anal tone. no head tilt etc. could right itself if crossed hind legs.
all foot pads and accessory carpal pads ulcerated
diffuse alopecia, esp around nose/face/feet
severe dental dz
panting, SHM 2-3/6 heard more on rt side to me, lungs sounded a little wheezy? no nasal discharge seen.
repeated skin scrape =neg from tail, feet, nose, top of head
disc w/O continuing tx for at least next 2-4 wk with oral ivomec and take off goodwinol and lyme sulfur dip. (Nervous though a little with this due to recent resp distress syndrome in past?but I thought Ivomec doses in oral syrup so little:1% ivomec into 108ml cherry syrup-day 1 50ug/kg
day 2-3 100ug
day 4-6 150 ug
day 7-9 200ug
day 10-16 300ug
day 17-45 400ug)
also continued dog on oral baytril 22mg sid x next 3 wk
upon PE dog seemed to have abdominal pain in cranial abdomen but couldn't really palpate anything specific. just felt bloated. dog looks like a goat! disc w/O I was more worried about something going on internally than just skin problem. O okayed repeated bdwk and x-rays.
bdwk:hct 30.5% (NL=37%)
WBC normal at 12.68
plt 1121(NH=500)
chem:Bun 31 (NH=27)
Cr wnl at 0.7
GGT=8(NH=7) and ALKP 657 (NH=212)--no one knows if he is PU/PD/PP?-cushings? emaciation/malnourished? bone?
On rectal exam dog does have a little soft stool with some blood tinge | Hepaticospleenomegally? | No entrapment of the epiglottis? |
Presented for 1st time with 9 yr old MN 10# westie from westie rescue group. On drive up here from Smithtown, Long Island? dog went into resp distress and was rushed to animal hospital down in westmoreland, ny? Stayed there for a few days. guess at the time dog was rescued from shelter down there dog had been bathed in peroxide and chlorohexidine?The vet at that time noted severe dental dz, 1/6 lf SHM and abdomen felt bloated, facial alopecia and pruritis. Bdwk was run then cbc/chem/t4 AND 4dx HWT.
I don't have the specifics all the faxed medical report says is elevated bun, trig's, neuts, wbcs and slightly low pcv. T4? HWT was neg. Dog was placed on baytril for a week 22mg sid. skin scrape was + for Sarcoptic mange and dog was given 1% ivermec injection. At hosp dog had diarrhea. dog given ace for excessive barking and anxiety. T=99.1 HR=120 RR=40.
1 wk later dog was given another dose of ivermec injection and was neg for sarcoptic but + for demodex. dog was sent home with goodwinol ointment and lyme sulfur dip.
Dog came in today to recheck skin for mites as many other dogs at foster home and because dog seemed weak couldn't walk. Although was walking around ok in exam room. On PE today here by me:
dog was barking and happy......but emaciated/cachexic with BCS=1-2/9!!!!!
normal temp=100.4, mm=pk/mm=2 sec/good femoral pulses
didn't seem ataxic , although hind legs seemed to high hitch? flip forward a little? CP intact all 4 feet. good anal tone. no head tilt etc. could right itself if crossed hind legs.
all foot pads and accessory carpal pads ulcerated
diffuse alopecia, esp around nose/face/feet
severe dental dz
panting, SHM 2-3/6 heard more on rt side to me, lungs sounded a little wheezy? no nasal discharge seen.
repeated skin scrape =neg from tail, feet, nose, top of head
disc w/O continuing tx for at least next 2-4 wk with oral ivomec and take off goodwinol and lyme sulfur dip. (Nervous though a little with this due to recent resp distress syndrome in past?but I thought Ivomec doses in oral syrup so little:1% ivomec into 108ml cherry syrup-day 1 50ug/kg
day 2-3 100ug
day 4-6 150 ug
day 7-9 200ug
day 10-16 300ug
day 17-45 400ug)
also continued dog on oral baytril 22mg sid x next 3 wk
upon PE dog seemed to have abdominal pain in cranial abdomen but couldn't really palpate anything specific. just felt bloated. dog looks like a goat! disc w/O I was more worried about something going on internally than just skin problem. O okayed repeated bdwk and x-rays.
bdwk:hct 30.5% (NL=37%)
WBC normal at 12.68
plt 1121(NH=500)
chem:Bun 31 (NH=27)
Cr wnl at 0.7
GGT=8(NH=7) and ALKP 657 (NH=212)--no one knows if he is PU/PD/PP?-cushings? emaciation/malnourished? bone?
On rectal exam dog does have a little soft stool with some blood tinge | Abdominal mass? | What does her diet consist? |