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HI
Zoe is a 13 year old M/N DSH. 7.4 kg
In October 2012, he was seen for Pu/PD, increased appetite and 7.8 % wt loss.
HIs BG was 21.9 mmol/L and frucotsamine 508 umol/L. Unable to get urine at clinic and at home. Clients will NOT leave cat at clinic. So can't do BG curve (although I don't usually, anyways). Owners will not do a curve at home either.
The owners are a bit strange about their cat. Really protective, more so than even my strangest cat client. They have gotten better. Just so you know why I've done what I've done.
The owners wanted to try Zoe on only canned food first.
1 month later, his BG was 19, fruc 471.
Although very reluctant, owners started on lantus 1 unit BID. I start here as I've had cats become hypoglycemic on this dose.
1 month later BG 21.7 fruc 659. Only canned, owners insistent giving insulin properly, storing properly. Won't come in for anosther demo.
Wouldn't increase insulin. Stayed at 1 unit BID, Tried Canned DM only, no other diets.
1 month later BG 23.1 fruc 667,
Increased insulin to 2 units BID
1 month later BG 24.9 fruc 559. Finally U/S sg 1.045, glucose 4 plus
Increased insulin to 2.5 units BID
2 months later BG 20.8, fruc 565.
Increased insulin to 3 units BID
1 month later BG 24.2, fruc 487.
Cat is very stressed and fractious so not sure how accurate BG is. Owners won't do BG's at home.
Zoe was gaining weight but lost 3 % at last visit.
No more Pu/PD since off dry.
Can't do BG curve. spec fpli was normal.
Haven't been able to get more urine.
Should I increase insulin with this info? or do you suggest anything I'm not thinking of?
Thanks! I usuallly get my diabetics off insulin after the first month! | Any other health issues that could be causing insulin resistance, such as dental disease, uti, any liver or gi disease? | What is the weight and bcs of the cat? |
Hi Everyone,
Here I am again with my own mutant cat...
"Winky" is a 12 y/o MC DSH, wt = 10#. He has had a host of health issues over the years but the currently relevant ones are renal insufficiency (after a presumptive blocked ureter secondary to a moving nephrolith) & insulin-resistant diabetes.
My problem lies with managing his diabetes & I need HELP! I diagnosed him with diabetes about 7 weeks ago. Urine culture at that time was negative, no ketones, & his BUN/creat were stable in the upper end of the "normal" range. A routine CBC/chemistry panel at that time was otherwise fairly unexciting. (Sorry, I don't have those numbers with me.) I didn't do a Usg at the time because he was PU/PD - his Usg up until now has sat between about 1.018 & 1.025.
So, I started him on glargine at 1 u SQ BID. Once every 7-8 days I would test a pre-meal/insulin glucose & it was always in the mid to upper 600's. I'd increase by 1 unit, watch carefully for behavior changes, occasionally check a midday glucose as well & go another week. When he hit 5 units BID & still had no change in numbers or improved behavior (PU/PD had actually worsened & he was beginning to act somewhat reclusive), I started to get really concerned. Glucose checks q 4 hours showed a flatline pattern in the mid-600's.
IGF1 is pending (won't have results for probably another week). fPLI was normal at 3.3. Abdominal ultrasound was attempted but he was too full of feces for a good scan - we are doing another this afternoon. Another urine culture was negative at 48 hrs. Urine is negative for ketones. Chest rads appear clean & his free T4 by ED is still pending. I repeated his CBC/Chem: Ca+2 was 10.3, TP = 8.1 (globulin = 3.9 & albumin slightly high at 4.2), BUN = 36, creat = 1.4, Na/K+ low at 27 (sodium = 147, potassium = 5.4) HCT = 31% (low for our altitude at 6500 ft), WBC WNL at 10.9K.
Soo...He was up to 7 u glargine BID & I'd started giving it IM in the hindquarters with no improvement. He is still eating like a champ. He lost weight initially but eats like a porker & is maintaining now. He still gets canned k/d with his insulin but since I am having to leave food down all the time for him he is getting dry d/d (because of the other household cat's IBD - can't separate them & meal-feeding is now out). Muscle mass isn't great, he is pot-bellied & drinking like a fish. He is also having difficulty with poor bowel motility - I have him on 2.5 mg cisapride PO BID & Miralax approx. 1 tsp BID, but he hasn't had a bowel movement without an enema in over a week. He is not passing any formed stool with his enemas (just liquid diarrhea) so I am thinking it is motility & not obstipation that is giving him trouble. Based on his lack of response, the internist I consulted with suggested switching to detemir insulin instead. We started him last night on one unit & moved to the intended 2 u SQ BID this AM. 4 hours post insulin he is so high he is not even registering on the AlphaTrak.
How fast can I change his insulin dose - every 7 days or so like glargine? Would you simply start him at a higher dose? He's a very tolerant cat but he is hitting his limits (& so is my bank account). I am concerned that he will crash before we can get this solved. He doesn't feel great now :( Would you keep him where he is for the full week & add a small amount of regular crystalline insulin to his AM regimen (after I check a BG)?
I'd greatly appreciate any advice you can give!
Thanks,
☼ | He's normotensive, correct? | Was she ketonuric when she presented emergently? |
Greetings!!
Zorro is a 17 year old MN main coon cat who was diagnosed with diabetes in Aug. 2012. At the time he also had a cystitis and was placed on clavaseptin for 2 weeks. At that time he had a very elevated glucose and a wbc count of 31 (5.5-19.5). All else was normal.
He was started on Lantus at 2 units BID and 10 days later his BG was 11.3mmol/L. He seemed to be doing well but 2 weeks later he came in for vomiting and diarhhea and was very dehydrated. BG was 3.7mmol/L. Owner had also noticed blood in urine. A repeat U/A confirmed lots of RBC and WBC so we did an U/S which revealed pyelonephritis. He was placed on Clavamox and Baytril for 2 weeks. A repeat U/A was not done but owner reported cat doing well.
A week after this episode we did a fructosamine which came back at 372 (210-418). Lab commented that it ws unusual for diabetic cat to have fructosamine return to normal and wondered if cat was still insulin dependant.
On Nov. 28th 2012 his BG was 13.3mmol/L so we recommended recheck in 2 months. Weight 6.14kgs
He came back March 6/13 and his BG was 26.6mmol/L!! Interestingly enough, owners report that he stayed PU/PD since he was diagnosed. We increased to 3units BID and saw him again after 2 weeks. His BG was then 20.2mmol/L and a urine stick gave us 4+ glucode so we increased insulin to 3.5 units BID. Weight 6.3kgs.
April 3/13 his BG was 22.3mmol/L. so we increased to 4 units BID. Weight 6.63kgs.
April 17, BG is 18.0mmol/L so again increased to 5units BID.
May 1st, BG is 21.7mmol/L but owner reports less PU/PD. increased to 6 units BID.
May 22/13, BG is 19.3mmol/L. Weight is 6.94kgs. The cat has been consistently gaining weight over the last few months and his abdomen feels quite bloated. He has been on a combination of dry S/O and canned metabolic so owner will decrease the amount of dry and increase insulin to 7 units BID.
Results are all over the place but from the last U/A it dose not look like a Somogiy issue but I am pretty close to as high as I dare with insulin.
Where to go from here with this 17 year old cat!! We have not repeated bloodwork which I am sure you will suggest but is there any point to a blood curve with the poor control we have. I am also concerned that he has not been regulated since November and I wonder if my waiting 2 weeks between insulin dose increases is too long. Thanks for the feedback. | How much does he weigh? | Is the dog also on a high fiber diet? |
I'm trying to treat a 10 year old dachshund that has been diagnosed with diabetes. His owner has tried giving insulin injections. She is now refusing to do them. She is convinced she is hurting him. I have told her there is nothing else that I can do to help him, but she is begging me for another solution. Is there anything else that she can do that I'm not aware of?
Thanks,
☼ | Is the dog truly pitching a fit during the injections? | What is the dogs true weigh in kg/pounds? |
I'm trying to treat a 10 year old dachshund that has been diagnosed with diabetes. His owner has tried giving insulin injections. She is now refusing to do them. She is convinced she is hurting him. I have told her there is nothing else that I can do to help him, but she is begging me for another solution. Is there anything else that she can do that I'm not aware of?
Thanks,
☼ | Or is the owner frightened of needles? | So, how many calories/day does she currently get? |
I'm trying to treat a 10 year old dachshund that has been diagnosed with diabetes. His owner has tried giving insulin injections. She is now refusing to do them. She is convinced she is hurting him. I have told her there is nothing else that I can do to help him, but she is begging me for another solution. Is there anything else that she can do that I'm not aware of?
Thanks,
☼ | Have you watched the process? | If the dog is truly in the insulin-resistant range, then start first by reviewing the simple management problems that can be going wrong e.g. can the owner give the insulin? |
Hi all,
I have a 6yo nm Miniture Schnauzer who was diganosed with diabetes on 3/14/13. He presented at this time for chronic vomiting of 1 day duration. Bloodwork at this time was as follows: glucose 656, BUN 53, Na 123, K 3.1, Cl 68, T4 0.9, cholesterol 594, ALP 1120, and high + on pancreas specific lipase test. The U/A showed glucose and ketones. He was started on 10 units Humulin N BID. His first glucose curve (weight was 31.6#) was on 4/2 as follows with 10 units insulin given at 7am: 8:15= 396; 10:50 = 241; 12:30 = 342; 2:38 = 378; 4:40 = 440. At this point the insulin was increased to 12 units BID.
Here's where it gets weird. On 5-13 (first time I had seen the dog), he presented for having episodes of falling over, jerking, and shaking from Friday-Sunday (this was on a Monday and the owners did not know that we had emergency on-call). They had continued to give the insulin despite these signs and were giving 11 units BID. His weight was down to 30# 7 oz. I did an blood glucose and it was 33! Gave him IV dextrose and food (which he ate ravenously). One hour later the blood glucose was 27, then 2.5 hours after that it was 45. No insulin given overnight or next morning. The next day his blood glucose was 431. At this point I decreased his insulin to 9 units BID Humulin N, continue feeding W/D food only, and do a glucose curve in two weeks.
Today (5/24) dog presented with having symptoms of not being able to stand/lost balance. O gave kayro syrup PO and seemed to help. Did not give insulin last night or this morning. O stated that dog at at 7am. Weight was 29# 2 oz. Blood glucose at 10am was 236. I drew blood for a senior panel and U/A (results will be in tomorrow). Is it possible for this dog's pancreas to start to 'convert' to being sensitive to the insulin? I thought that really only happened occasionally in cats. He is on benazepril 5mg SID for heart disease (has a grade 5/6 heart murmur). Any thoughts? This last time there has been no change in water intaker per O and still eats food ravenously.
Michelle DVM | It's possible he was more insulin resistant due to uti (was urine culture done? | How was this diagnosed? |
Hello,
I would really like your help in this case. I am a little unsure on how to proceed. I saw a 4 year old female spayed boxer few days ago for PU/PD. The owner just moved in with his girlfriend and her dog. Both the dogs have known each other since september 2012 Since moving in few months ago, Jasmin, the boxer started to urinate in the house and the other dog has separation anxiety. Per owner, there is always some urine when she gets up from rest. She also drinks a lot and urinates in front of the owner. Per owner she goes outside and urinates then comes inside and urinates as well.
She is also licking her vulva a lot. Physical exam was normal, no vaginal discharge as well, does not strain to urinate as well. I ran bloodwork and urinalysis via free catch. I have attached it below.
My thoughts are it is behavioral or perhaps anxiety but that does not account for increased water consumption, does it? With the mildly elevated creatinine, I was thinking of running a Urine protein creat ratio to rule out any protein losing nephropathy and/or ultrasound and/or urine culture? Could it be diabetes insipidus? Should I have them do a water deprivation test? I am just throwing things out because I am at a loss.
I would appreciate any help in this case. | What's up with that calcium? | Was he on topical steroids for the uveitis? |
Hello,
I would really like your help in this case. I am a little unsure on how to proceed. I saw a 4 year old female spayed boxer few days ago for PU/PD. The owner just moved in with his girlfriend and her dog. Both the dogs have known each other since september 2012 Since moving in few months ago, Jasmin, the boxer started to urinate in the house and the other dog has separation anxiety. Per owner, there is always some urine when she gets up from rest. She also drinks a lot and urinates in front of the owner. Per owner she goes outside and urinates then comes inside and urinates as well.
She is also licking her vulva a lot. Physical exam was normal, no vaginal discharge as well, does not strain to urinate as well. I ran bloodwork and urinalysis via free catch. I have attached it below.
My thoughts are it is behavioral or perhaps anxiety but that does not account for increased water consumption, does it? With the mildly elevated creatinine, I was thinking of running a Urine protein creat ratio to rule out any protein losing nephropathy and/or ultrasound and/or urine culture? Could it be diabetes insipidus? Should I have them do a water deprivation test? I am just throwing things out because I am at a loss.
I would appreciate any help in this case. | Have you rechecked this? | How much should he weigh? |
Hello,
I would really like your help in this case. I am a little unsure on how to proceed. I saw a 4 year old female spayed boxer few days ago for PU/PD. The owner just moved in with his girlfriend and her dog. Both the dogs have known each other since september 2012 Since moving in few months ago, Jasmin, the boxer started to urinate in the house and the other dog has separation anxiety. Per owner, there is always some urine when she gets up from rest. She also drinks a lot and urinates in front of the owner. Per owner she goes outside and urinates then comes inside and urinates as well.
She is also licking her vulva a lot. Physical exam was normal, no vaginal discharge as well, does not strain to urinate as well. I ran bloodwork and urinalysis via free catch. I have attached it below.
My thoughts are it is behavioral or perhaps anxiety but that does not account for increased water consumption, does it? With the mildly elevated creatinine, I was thinking of running a Urine protein creat ratio to rule out any protein losing nephropathy and/or ultrasound and/or urine culture? Could it be diabetes insipidus? Should I have them do a water deprivation test? I am just throwing things out because I am at a loss.
I would appreciate any help in this case. | So this dog is purposely urinating in the house....it's not unaware or incontinent? | Do you have intraoral radiographs? |
Hello,
I would really like your help in this case. I am a little unsure on how to proceed. I saw a 4 year old female spayed boxer few days ago for PU/PD. The owner just moved in with his girlfriend and her dog. Both the dogs have known each other since september 2012 Since moving in few months ago, Jasmin, the boxer started to urinate in the house and the other dog has separation anxiety. Per owner, there is always some urine when she gets up from rest. She also drinks a lot and urinates in front of the owner. Per owner she goes outside and urinates then comes inside and urinates as well.
She is also licking her vulva a lot. Physical exam was normal, no vaginal discharge as well, does not strain to urinate as well. I ran bloodwork and urinalysis via free catch. I have attached it below.
My thoughts are it is behavioral or perhaps anxiety but that does not account for increased water consumption, does it? With the mildly elevated creatinine, I was thinking of running a Urine protein creat ratio to rule out any protein losing nephropathy and/or ultrasound and/or urine culture? Could it be diabetes insipidus? Should I have them do a water deprivation test? I am just throwing things out because I am at a loss.
I would appreciate any help in this case. | Urinating on purpose or incontinence upon returning inside? | The platelets are normal? |
Hello,
I would really like your help in this case. I am a little unsure on how to proceed. I saw a 4 year old female spayed boxer few days ago for PU/PD. The owner just moved in with his girlfriend and her dog. Both the dogs have known each other since september 2012 Since moving in few months ago, Jasmin, the boxer started to urinate in the house and the other dog has separation anxiety. Per owner, there is always some urine when she gets up from rest. She also drinks a lot and urinates in front of the owner. Per owner she goes outside and urinates then comes inside and urinates as well.
She is also licking her vulva a lot. Physical exam was normal, no vaginal discharge as well, does not strain to urinate as well. I ran bloodwork and urinalysis via free catch. I have attached it below.
My thoughts are it is behavioral or perhaps anxiety but that does not account for increased water consumption, does it? With the mildly elevated creatinine, I was thinking of running a Urine protein creat ratio to rule out any protein losing nephropathy and/or ultrasound and/or urine culture? Could it be diabetes insipidus? Should I have them do a water deprivation test? I am just throwing things out because I am at a loss.
I would appreciate any help in this case. | Large or small volume? | When he had his abdominal ultrasound last year did the ultrasonographer attribute his elevated liver values to endocrinopathy? |
Hello,
I would really like your help in this case. I am a little unsure on how to proceed. I saw a 4 year old female spayed boxer few days ago for PU/PD. The owner just moved in with his girlfriend and her dog. Both the dogs have known each other since september 2012 Since moving in few months ago, Jasmin, the boxer started to urinate in the house and the other dog has separation anxiety. Per owner, there is always some urine when she gets up from rest. She also drinks a lot and urinates in front of the owner. Per owner she goes outside and urinates then comes inside and urinates as well.
She is also licking her vulva a lot. Physical exam was normal, no vaginal discharge as well, does not strain to urinate as well. I ran bloodwork and urinalysis via free catch. I have attached it below.
My thoughts are it is behavioral or perhaps anxiety but that does not account for increased water consumption, does it? With the mildly elevated creatinine, I was thinking of running a Urine protein creat ratio to rule out any protein losing nephropathy and/or ultrasound and/or urine culture? Could it be diabetes insipidus? Should I have them do a water deprivation test? I am just throwing things out because I am at a loss.
I would appreciate any help in this case. | When she goes outside and urinates, does she strain or posture in multiple places? | No fleas or other parasites? |
Hello,
I would really like your help in this case. I am a little unsure on how to proceed. I saw a 4 year old female spayed boxer few days ago for PU/PD. The owner just moved in with his girlfriend and her dog. Both the dogs have known each other since september 2012 Since moving in few months ago, Jasmin, the boxer started to urinate in the house and the other dog has separation anxiety. Per owner, there is always some urine when she gets up from rest. She also drinks a lot and urinates in front of the owner. Per owner she goes outside and urinates then comes inside and urinates as well.
She is also licking her vulva a lot. Physical exam was normal, no vaginal discharge as well, does not strain to urinate as well. I ran bloodwork and urinalysis via free catch. I have attached it below.
My thoughts are it is behavioral or perhaps anxiety but that does not account for increased water consumption, does it? With the mildly elevated creatinine, I was thinking of running a Urine protein creat ratio to rule out any protein losing nephropathy and/or ultrasound and/or urine culture? Could it be diabetes insipidus? Should I have them do a water deprivation test? I am just throwing things out because I am at a loss.
I would appreciate any help in this case. | Is there obvious hematuria? | The owner can accurately measure and then inject the insulin--using u40 syringes? |
Hi
I have a 1yr 3 month year old Maltese terrier X, female desexed, wt 3.3kg. She presented today, collapsed, when I got to her she had a very faint heart rate and was exhibiting what I thought was agonal gasping. Owner reports that she had staggered and fell against a wall and urinated herself then he was brought straight in. Her jaw was clamped shut and she had defecated, I managed to intubate and after 3 minutes of oxygen she appeared to regain consciousness, heart beat was strong and she started to breath herself, i extubated. Approximately 3 minutes after this she was sitting up, still a little flat but acting as if nothing had happened. I assumed that she had had a seizure, and was stil a little flat as she was postictal. I ran bloods. As I was waiting for bloods she defecated, loose faeces with red jam, I palpated her abdomen and she was extremely painful. She was hyper salivating also.
Haematology;
WBC 12.44 (6-17)
LYM 6.47 (1-4.8) HIGH
MON 0.32 (0.2-1.5)
NEU 5.37 (3-12)
EOS 0.21 (0-0.8)
BAS 0.07 (0-0.4)
RBC 6.77 (5.5-8.5)
HGB 16.1 (12-18)
HCT 51.35 (37-55)
MCV 76 (60-77)
MCH 23.9 (19.5-24.5)
MCHC 31.4 (31-34)
PLT 317 (200-500)
Biochemistry;
ALB 2.9 (2.5-4.4)
ALP 24 (20-150)
ALT 407 (10-118) HIGH
AMY 180 (200-1200) LOW
TBIL 0.5 (0.1-0.6)
BUN 21 (7-25)
CA 9.6 (8.6-11.8)
PHOS 7.8 (2.9-6.6) HIGH
CRE 1.1 (0.3-1.4)
GLU 388 (60-110) HIGH
NA+ 142 (138-160)
K+ 4.3 (3.7-5.8)
TP 4.9 (5.4-8.2) LOW
GLOB 2.1 (2.3-5.2) LOW
T4 3.2 (1.1-4.0)
CHOL 183 (125-270)
After prompting the owners, they feel like she may have had some episodes similar to this before. She has days where she does not run around like usual but will lie around and seem very lethargic.
Initially as I thought this was a seizure, I was concerned that the elevation in ALT could indicate portosystemic shunt with subsequent hepatic encephalopathy and that the hyperglycaemia was secondary to the seizure. However such a severe elevation in glucose has me confused, is this diabetes Mellitus? I am sorry I do not have a urinalysis at present, that is next on the list, I just wanted to see if there are any glaring differential diagnosis that i am missing. This does seem very young for DM.
Thanks in advance for any help you can give me,
Kind Regards,
☼ | Plus, the owner doesn't seem to really be describing pu/pd....not sure if she's lost weight? | Why does insulin cost more than ever? |
Glargine is now $176 for a bottle. I have a well regulated 20 pound diabetic cat on glargine but the owner has requested a change due to the ever increasing cost of glargine. I have gotten quite used to glargine in cats and haven't used Humulin N in cats for several years. How do I make the switch? Start over as if he's a new diabetic? Any tips? This makes me nervous b/c he has been doing so well! Thanks for your help. | How much glargine is the cat on now? | So the cortisols are the highest they've been despite the dog feeling ill? |
"Katie" is an unusual diabetic. Her owner is a very motivated cat lover who does at home Alpha Trak BGs. She has had a history of unusual BG readings and she had an abdominal ultrasound and exploratory laparotomy at a vet school satellite critical care facility where they diagnosed a partial biliary obstruction and performed a cholecystojejunostomy and on biopsy the two out of three pathologists at the vet school diagnosed Small Cell lymphoma and Metastatic Mast Cell neoplasia in the intestinal samples and mesenteric lymph nodes. One pathologist diagnosed IBD and did not mention mast cell neoplasia. No primary was found for the mast cell metastatic diagnosis. She is not on any medication for either lymphoma or mast cell disease. The owner did not want to give her any medication and she fights it mightily. She is Felv and FIV negative. She had 4+ E.Coli in her gall bladder C&S which was treated. The owner has had her on PZI BID. She has been diabetic at least 1.5 years. She is 10.6 lb and has gained almost one pound recently.
Several days ago the owner did a BG curve. His 9am (zero hr) BG was 201, he meant to give her 2 units but inadvertently gave 3 units sq. Her two hr BG was 279. Her four hr BG was 298. Her six hr BG was 212. Her 8 hr BG was 251, 10 hr 285, 12 hr 343. He then gave 3 units PZI at 9pm and in the morning her 9am/zero hr BG was 196. He gave her 2 units. Her six hr BG was 351 and her 12 hr was 396. Yesterday her 9am BG was 140 and the owner gave her 1.5 U PZI.
Why do you think the AM zero hour BG is so low given that the evening 12 hr BG was 351 and 396? Why does her BG rise after her morning PZI. We have done several BG curves on her but always with two hr readings. Could she be Somogyi(ing) at some point between the zero hr and her first two hr BG?
Her most recent fructosamine was 319 (191 - 349 normal).
Do you think we should switch to Lantus or Detemir? What do you think about her Small cell lymphoma and mesenteric lymph node mast cell diagnoses? Playing a role? She eats Fancy feast cans. Won't eat DM.
Thank you so much. | As far as the insulin, any reason why this cat was not placed on lantus from the get-go? | Lepto serology? |
Hello all,
Today I was called in to see a hypothermic, seizing 8 year old diabetic male castrated toy poodle. He had been boarding at our hospital and was found in this state by a staff member. Upon my arrival the dog had a temperature of 94.6 degrees and his BG was too low to be read by our glucometer. After administering 5cc of 50% dextrose slowly diluted in LRS and also 2 cc of valium IV, the dog stopped seizing and became more responsive. His temperature crept up and I started him on 5% dextrose at a 1/2 maintenance dose (12 ml/hr, 19.6 lb. body weight). His temperature improved. His mentation, given the dose of valium, also seemed appropriate. We are unsure how long he was cold and seizuring for. He was found at 3pm. By 5 pm he was normothermic after gradual warming. His ongoing hypoglycemia concerns me. The attendant said that the dog had been eating OK, but not great. He receives 4 units of lantus BID and has since diagnosed with diabetes in Nov. 2011 (when he weighed 28 lbs). He received 4 units last night and this morning.
Here are the blood glucose readings and changes to his treatment:
350 pm after bolus of dextrose 210
425 131
450 43 - gave bolus of 50 cc of 5% dextrose and increased rate to 25 ml /hr
5 pm 70
515 31 bolus of 2 cc 50% dextrose
530 25 increase dextrose to 10%
545 34 went out for a brief walk (off dextrose)
6 00 20! -attributed to walk and dc'd dextrose, dog's mentation OK bolus 10 cc 10% dextrose
615 37
630 34
715 40
750 41
820 26
850 32
935 35
1005 30
Obtained some glucagon from the owners friend (a pharmacist) reconstituted and used Buretrol to create 200 ng/ml solution for CRI and ran into line carrying 5% dextrose in Saline
Bolused glucagon @ 50 mg/kg. Glucagon CRI @ 23 ng/ml
1045 45
11 33
1120 28 - increased CRI to 40 ng/ml
1150 38
1210 48
1240 49
105 53 - had to rewrap catheter and change around some pumps at this point, so cri was not running for awhile
2 am 39
We are not a 24 hour hospital but I have been unable to convince the owners to bring the dog to such a facility. At the same time, I feel somewhat responsible for the dog given that he was here boarding. At 8am, his care passes to another doc. I'm curious if anyone has any ideas regarding how long the hypoglycemia can continue and how long we may need to treat for. The dog has done well neurologically, responds to people, and has gone on walks. He appears exhausted at this point though. The threads I've found on VIN involving patients who haven't improved seem to have had ongoing neuro issues. White count was normal and lytes have also been normal ( potassium slightly low but now supplemented @ 20 mEq/L).
I apologize in advance for any omissions or if anything is unclear.
Thanks!
/p | Is he eating now? | Do you have any video that you can post here so that we can see more about what you are describing? |
So I work at a clinic that does a lot of emergencies (ie manage the crisis and send to rDVM) and I have been on mat ve for a year so it has been a long time since I have maganaged a new diabetic. This owner does not wish to do glucose curves/readings at home. I apologize for the length of this case but I would like some advice on what we have done so far, what should next step be and what should be done differently in the future.
I am following these guidelines: http://beta.vin.com/Members/CE/C114/Library/PubCE2_M03631.htm
4 year old female spayed Bichon cross, 13.5 lbs
April 23
-dog presented to my colgue pupd for about a month, lethargic, weight loss (muscle wasting)-lab work attached
-labwork consistent with diabetes, healthy dka
-advised start NPH at 3 units BID, feed W/D
April 25
-hospitalized dog to rn/give first insulin dose and monitor for hypoglycemia
6:30 am-1/2 cup W/D, 3 units NPH
1:40p 15 mmol/L
5:00p 13.8 mmol/L
-dog did not become hypoglycemia, ok to give 3 units and curve 1 week
May 2
-hospitalized for BG curve, 13.8 lbs, not lethargic, eating well
7 am 25.9 mmol/L 1/2 cup W/D, 3 units NPH
9 am 21.4 mmol/L
11 am 16.6 mmol/L
12:30 3/4 tin Cesar
1pm 19.3 mmol/L
3p 20.5 mmol/L
5 20.4 mmol/L
7 23 mmol/L 1/2 cup W/D
-sufficient nadir not reached, increase to 4 units
May 9
-hospitalized for BG curve, 14 lbs
7 am 20.9 mmol/L 1/2 cup W/D 4 units NPH
9 am 17.6 mmol/L
11-missed
not sure if fed 12:30 or not
1pm 18.1 mmol/L
3 pm 20.4 mmol/L
-curve stopped as low nadir not reached, increase to 5 units, told owner to stop feeding mid day Cesar, owner really wants to feed mid day so ok to feed W/D TID
May 16
-hospitalized for BG curve, 13.3 lbs
730 am 1/2 cup W/D 5 units NPH
930 am 15.2 mmol/L
1130 am 12 mmol/L
1230 1/2 cup W/D
130 pm 17.7 mmol/L -even though not acheiving low nadir, continued to see if 2nd low point in afternoon
330 pm 20.4 mmol/L
530 pm 16.1 mmol/L
730 pm 13.6 mmol/L
-nadir appear to be around 1130, low nadir not reached, increase to 6 units
May 23
-hospitalized for BG curve, 13.8 lbs
730 am 1/2 cup WD 6 units NPH
930 am 11.2 mmol/L
1130 am 11.4 mmol/L
-stopped BG curve as low nadir not reached, increase to 7 units
Plan for next week is to check pre insulin BG to ensure it is above 10 mmol/L, check at 1130 and if between ideal nadir of 5-8 mmol/L, check before next insulin dose due and if above 10 mmol/L then correct dose has likely been found
-owner is stressed by giving insulin injections and wants to try an insulin pen (against my advice)
Should I redo a curve when he starts the insulin pen or not because it is the same dose?
Questions:
So is it normal for it to take this long to reach an appropriate dose? Most of my owners would probably have put the dog down by now.
Am I too focused on getting that nadir between 5-8 mmol/L? But if that isn't my focus, what is (other than clinical signs)?
Is the mid day feeding really messing everything up?
Any critique on what has been done so far and my next step plans would be appreciated.
☼ | Does that make sense? | So glad you changed him to glargine : ) i wonder if he ate as well as the owner thought that day? |
So I work at a clinic that does a lot of emergencies (ie manage the crisis and send to rDVM) and I have been on mat ve for a year so it has been a long time since I have maganaged a new diabetic. This owner does not wish to do glucose curves/readings at home. I apologize for the length of this case but I would like some advice on what we have done so far, what should next step be and what should be done differently in the future.
I am following these guidelines: http://beta.vin.com/Members/CE/C114/Library/PubCE2_M03631.htm
4 year old female spayed Bichon cross, 13.5 lbs
April 23
-dog presented to my colgue pupd for about a month, lethargic, weight loss (muscle wasting)-lab work attached
-labwork consistent with diabetes, healthy dka
-advised start NPH at 3 units BID, feed W/D
April 25
-hospitalized dog to rn/give first insulin dose and monitor for hypoglycemia
6:30 am-1/2 cup W/D, 3 units NPH
1:40p 15 mmol/L
5:00p 13.8 mmol/L
-dog did not become hypoglycemia, ok to give 3 units and curve 1 week
May 2
-hospitalized for BG curve, 13.8 lbs, not lethargic, eating well
7 am 25.9 mmol/L 1/2 cup W/D, 3 units NPH
9 am 21.4 mmol/L
11 am 16.6 mmol/L
12:30 3/4 tin Cesar
1pm 19.3 mmol/L
3p 20.5 mmol/L
5 20.4 mmol/L
7 23 mmol/L 1/2 cup W/D
-sufficient nadir not reached, increase to 4 units
May 9
-hospitalized for BG curve, 14 lbs
7 am 20.9 mmol/L 1/2 cup W/D 4 units NPH
9 am 17.6 mmol/L
11-missed
not sure if fed 12:30 or not
1pm 18.1 mmol/L
3 pm 20.4 mmol/L
-curve stopped as low nadir not reached, increase to 5 units, told owner to stop feeding mid day Cesar, owner really wants to feed mid day so ok to feed W/D TID
May 16
-hospitalized for BG curve, 13.3 lbs
730 am 1/2 cup W/D 5 units NPH
930 am 15.2 mmol/L
1130 am 12 mmol/L
1230 1/2 cup W/D
130 pm 17.7 mmol/L -even though not acheiving low nadir, continued to see if 2nd low point in afternoon
330 pm 20.4 mmol/L
530 pm 16.1 mmol/L
730 pm 13.6 mmol/L
-nadir appear to be around 1130, low nadir not reached, increase to 6 units
May 23
-hospitalized for BG curve, 13.8 lbs
730 am 1/2 cup WD 6 units NPH
930 am 11.2 mmol/L
1130 am 11.4 mmol/L
-stopped BG curve as low nadir not reached, increase to 7 units
Plan for next week is to check pre insulin BG to ensure it is above 10 mmol/L, check at 1130 and if between ideal nadir of 5-8 mmol/L, check before next insulin dose due and if above 10 mmol/L then correct dose has likely been found
-owner is stressed by giving insulin injections and wants to try an insulin pen (against my advice)
Should I redo a curve when he starts the insulin pen or not because it is the same dose?
Questions:
So is it normal for it to take this long to reach an appropriate dose? Most of my owners would probably have put the dog down by now.
Am I too focused on getting that nadir between 5-8 mmol/L? But if that isn't my focus, what is (other than clinical signs)?
Is the mid day feeding really messing everything up?
Any critique on what has been done so far and my next step plans would be appreciated.
☼ | Do you have the owner feed the dog at home and give insulin before bringing the dog in? | Is the client performing spot checks or 12-hour curves? |
I have been using glargine for some time now in cats and have to say I have not been totally happy - find it very difficult to maintain an even glucose level. In general I find cats are all over the map when monitoring glucose levels. I would like to switch one cat over to Caninsulin (Vetsulin) but no sure if I can just stop one & swich to the other considering the difference in units or start at the usual dosage of 1 U and go from there. Any further advice on glargine should I not even be going at it the right way or is it just trying to find the right insulin for each patient?
☼ | Oh - and i must ask if you are also changing the diet? | Pu/pd weight loss? |
"Salem" is a 9 month old, FS, DSH cat that presented on 4/29/13 with a 1 week history of inappropriate urination. She is a fractious cat and had to be boxed down for exam and blood/urine collection. Her urinalysis revealed a glucose of 1000 mg/dl and her blood glucose was 441 mg/dl. She had rod bacteria in her urine. She was started on Zenequin and seemed to improve initially. A fructosamine sent out on 4/29/13 was 291 umol/L (reference range 191-349 umol/L).
I saw her for a recheck on 5/17/13 and the owner felt that she was 100% improved. I sedated her and collected a urine sample via cysto: SG >1.040, glucose 1000 mg/dl, ketones 15 mg/dl, sediment quiet. Her blood glucose was 424 mg/dl. I started her on Purina DM food and called our local internist for advice. He recommended a urine culture for possible pyelonephritis. We sent out a sterile urine culture and sensitivity along with a UA to Idexx on 5/21/13. By this time, Salem had started to look lousy again and had lost 10 oz. She had been off antibiotics for 8 days. I started her back on Zenequin.
I got the culture back on 5/24 and there was no growth. Her UA revealed 3+ glucose (1000 mg/d) and 2+ ketones. Everything else was WNL.
I saw her this morning and she is down from 8# initially to 6# 14 oz. She is not eating and is lethargic. Her blood glucose this morning was 528 mg/dl. I started her on glargine insulin, 1 unit BID.
Questions:
1. Why would a 9 month old cat become diabetic?
2. Should I be doing a further work-up to look for underlying issues?
3. Why would the initial fructosamine be within the reference range if her blood sugar was so high?
I have been seeing Salem since she was a kitten. She always appeared to be a thrifty cat and the client feels that her symptoms started suddenly the end of April. I spayed her on 1/31/2013 and her blood glucose pre-op was 97 mg/dl.
Thanks!
☼ | Is there any history of gi-related signs in this young cat? | Nooooo snacks between meals? |
What is the latest best starting insulin for an uncomplicated diabetes mellitus?
Thanks in advance. | For dogs or for cats? | Nodule? |
Florence is a 1 year old F/S Sheltie cross that had been previously diagnosed with Diabetes Insipidus at another clinic. She has been treated with compounded Desmopressin Ophthalmic solution 0.01% at a dose of 1 drop OU bid. The owners have commented that this has seemed effective but more recently it seems to be wearing off about 8-10 hours after dosing as evidenced by a farily predictable onset of PU/PD.
The owners did a trial of tid dosing which seemed to work very well for Florence. Can this safely be given tid long term or is there some other dosing change that would be recommended? Thank you for your assistance. | How did the other hospital confirm the diagnosis? | How should i treat elevated triglycerides? |
Babe is a spayed female DSH 4 year old lap kitty of a dear client. We diagnosed diabetes one month ago. Attempts to regulate her blood sugar have been futile. Blood work normal other than glucose, urine culture negative. We started on PZI at 2 u once daily and worked her up to 4 U without having good regulation,
Best glucose was at 18 hours (the owners wished to give insulin in the evening initially so that they could watch her at night after the injection. Even though I told them that isn't best, they are great clients so I ceded to their wishes initially. They have now changed to mornings, and that is what we have worked with recently.
We saw we weren't getting much movement with the insulin, and at 4 units we were actually seeing higher glucose readings, so we backed down again to 2 U.
Today we gave 2.5 U in hospital at 8:45 after feeding canned low carb./ high protein meal at 8:30. At 8:30, glucose on glucometer was 440. 9:15--Hi
10:10--Hi
10:40--325
12:30--408
1:44--474
2:45--Hi
Tomorrow we plan on going up to the 3.5 U where we actually saw a glucose in the 200s. We plan on testing as above, and seeing the length of time and numbers. We plan on going to BID injection if we think that will give us more hours under 180.
Any ideas or suggestions would be appreciated. Will post more tomorrow. | Which high protein/low carb canned food is she on? | Ultrasound? |
Babe is a spayed female DSH 4 year old lap kitty of a dear client. We diagnosed diabetes one month ago. Attempts to regulate her blood sugar have been futile. Blood work normal other than glucose, urine culture negative. We started on PZI at 2 u once daily and worked her up to 4 U without having good regulation,
Best glucose was at 18 hours (the owners wished to give insulin in the evening initially so that they could watch her at night after the injection. Even though I told them that isn't best, they are great clients so I ceded to their wishes initially. They have now changed to mornings, and that is what we have worked with recently.
We saw we weren't getting much movement with the insulin, and at 4 units we were actually seeing higher glucose readings, so we backed down again to 2 U.
Today we gave 2.5 U in hospital at 8:45 after feeding canned low carb./ high protein meal at 8:30. At 8:30, glucose on glucometer was 440. 9:15--Hi
10:10--Hi
10:40--325
12:30--408
1:44--474
2:45--Hi
Tomorrow we plan on going up to the 3.5 U where we actually saw a glucose in the 200s. We plan on testing as above, and seeing the length of time and numbers. We plan on going to BID injection if we think that will give us more hours under 180.
Any ideas or suggestions would be appreciated. Will post more tomorrow. | Is she obese? | Can you post the radiographs here? |
Babe is a spayed female DSH 4 year old lap kitty of a dear client. We diagnosed diabetes one month ago. Attempts to regulate her blood sugar have been futile. Blood work normal other than glucose, urine culture negative. We started on PZI at 2 u once daily and worked her up to 4 U without having good regulation,
Best glucose was at 18 hours (the owners wished to give insulin in the evening initially so that they could watch her at night after the injection. Even though I told them that isn't best, they are great clients so I ceded to their wishes initially. They have now changed to mornings, and that is what we have worked with recently.
We saw we weren't getting much movement with the insulin, and at 4 units we were actually seeing higher glucose readings, so we backed down again to 2 U.
Today we gave 2.5 U in hospital at 8:45 after feeding canned low carb./ high protein meal at 8:30. At 8:30, glucose on glucometer was 440. 9:15--Hi
10:10--Hi
10:40--325
12:30--408
1:44--474
2:45--Hi
Tomorrow we plan on going up to the 3.5 U where we actually saw a glucose in the 200s. We plan on testing as above, and seeing the length of time and numbers. We plan on going to BID injection if we think that will give us more hours under 180.
Any ideas or suggestions would be appreciated. Will post more tomorrow. | The owners can accurately measure and then inject the insulin? | Do you mean docp rather than cortrosyn? |
Babe is a spayed female DSH 4 year old lap kitty of a dear client. We diagnosed diabetes one month ago. Attempts to regulate her blood sugar have been futile. Blood work normal other than glucose, urine culture negative. We started on PZI at 2 u once daily and worked her up to 4 U without having good regulation,
Best glucose was at 18 hours (the owners wished to give insulin in the evening initially so that they could watch her at night after the injection. Even though I told them that isn't best, they are great clients so I ceded to their wishes initially. They have now changed to mornings, and that is what we have worked with recently.
We saw we weren't getting much movement with the insulin, and at 4 units we were actually seeing higher glucose readings, so we backed down again to 2 U.
Today we gave 2.5 U in hospital at 8:45 after feeding canned low carb./ high protein meal at 8:30. At 8:30, glucose on glucometer was 440. 9:15--Hi
10:10--Hi
10:40--325
12:30--408
1:44--474
2:45--Hi
Tomorrow we plan on going up to the 3.5 U where we actually saw a glucose in the 200s. We plan on testing as above, and seeing the length of time and numbers. We plan on going to BID injection if we think that will give us more hours under 180.
Any ideas or suggestions would be appreciated. Will post more tomorrow. | They're moving the injections around on her body every day? | Have you performed a rectal exam? |
Babe is a spayed female DSH 4 year old lap kitty of a dear client. We diagnosed diabetes one month ago. Attempts to regulate her blood sugar have been futile. Blood work normal other than glucose, urine culture negative. We started on PZI at 2 u once daily and worked her up to 4 U without having good regulation,
Best glucose was at 18 hours (the owners wished to give insulin in the evening initially so that they could watch her at night after the injection. Even though I told them that isn't best, they are great clients so I ceded to their wishes initially. They have now changed to mornings, and that is what we have worked with recently.
We saw we weren't getting much movement with the insulin, and at 4 units we were actually seeing higher glucose readings, so we backed down again to 2 U.
Today we gave 2.5 U in hospital at 8:45 after feeding canned low carb./ high protein meal at 8:30. At 8:30, glucose on glucometer was 440. 9:15--Hi
10:10--Hi
10:40--325
12:30--408
1:44--474
2:45--Hi
Tomorrow we plan on going up to the 3.5 U where we actually saw a glucose in the 200s. We plan on testing as above, and seeing the length of time and numbers. We plan on going to BID injection if we think that will give us more hours under 180.
Any ideas or suggestions would be appreciated. Will post more tomorrow. | They don't over- or under-shake the insulin? | How many calories/day does the dog currently get? |
Babe is a spayed female DSH 4 year old lap kitty of a dear client. We diagnosed diabetes one month ago. Attempts to regulate her blood sugar have been futile. Blood work normal other than glucose, urine culture negative. We started on PZI at 2 u once daily and worked her up to 4 U without having good regulation,
Best glucose was at 18 hours (the owners wished to give insulin in the evening initially so that they could watch her at night after the injection. Even though I told them that isn't best, they are great clients so I ceded to their wishes initially. They have now changed to mornings, and that is what we have worked with recently.
We saw we weren't getting much movement with the insulin, and at 4 units we were actually seeing higher glucose readings, so we backed down again to 2 U.
Today we gave 2.5 U in hospital at 8:45 after feeding canned low carb./ high protein meal at 8:30. At 8:30, glucose on glucometer was 440. 9:15--Hi
10:10--Hi
10:40--325
12:30--408
1:44--474
2:45--Hi
Tomorrow we plan on going up to the 3.5 U where we actually saw a glucose in the 200s. We plan on testing as above, and seeing the length of time and numbers. We plan on going to BID injection if we think that will give us more hours under 180.
Any ideas or suggestions would be appreciated. Will post more tomorrow. | They're using u40 syringes? | Were there any elevations in her liver values that would support hyperthyroidism? |
Babe is a spayed female DSH 4 year old lap kitty of a dear client. We diagnosed diabetes one month ago. Attempts to regulate her blood sugar have been futile. Blood work normal other than glucose, urine culture negative. We started on PZI at 2 u once daily and worked her up to 4 U without having good regulation,
Best glucose was at 18 hours (the owners wished to give insulin in the evening initially so that they could watch her at night after the injection. Even though I told them that isn't best, they are great clients so I ceded to their wishes initially. They have now changed to mornings, and that is what we have worked with recently.
We saw we weren't getting much movement with the insulin, and at 4 units we were actually seeing higher glucose readings, so we backed down again to 2 U.
Today we gave 2.5 U in hospital at 8:45 after feeding canned low carb./ high protein meal at 8:30. At 8:30, glucose on glucometer was 440. 9:15--Hi
10:10--Hi
10:40--325
12:30--408
1:44--474
2:45--Hi
Tomorrow we plan on going up to the 3.5 U where we actually saw a glucose in the 200s. We plan on testing as above, and seeing the length of time and numbers. We plan on going to BID injection if we think that will give us more hours under 180.
Any ideas or suggestions would be appreciated. Will post more tomorrow. | The pzi you're using is prozinc, not a compounded pzi, right? | Table food? |
Babe is a spayed female DSH 4 year old lap kitty of a dear client. We diagnosed diabetes one month ago. Attempts to regulate her blood sugar have been futile. Blood work normal other than glucose, urine culture negative. We started on PZI at 2 u once daily and worked her up to 4 U without having good regulation,
Best glucose was at 18 hours (the owners wished to give insulin in the evening initially so that they could watch her at night after the injection. Even though I told them that isn't best, they are great clients so I ceded to their wishes initially. They have now changed to mornings, and that is what we have worked with recently.
We saw we weren't getting much movement with the insulin, and at 4 units we were actually seeing higher glucose readings, so we backed down again to 2 U.
Today we gave 2.5 U in hospital at 8:45 after feeding canned low carb./ high protein meal at 8:30. At 8:30, glucose on glucometer was 440. 9:15--Hi
10:10--Hi
10:40--325
12:30--408
1:44--474
2:45--Hi
Tomorrow we plan on going up to the 3.5 U where we actually saw a glucose in the 200s. We plan on testing as above, and seeing the length of time and numbers. We plan on going to BID injection if we think that will give us more hours under 180.
Any ideas or suggestions would be appreciated. Will post more tomorrow. | Any reason that you don't use glargine? | What are you treating? |
I would appreciate any imput on a case our practice is working on. We "adopted" a 6 mo old St Ben pup that was extremely thin, had bilateral cataracts, frequent urination etc a month and a half ago. Chem panel revealed the obvious likelyhood of diabetes with blood glucoses running in the 400-500 ranges most of the time. We have been working hard to regulate and pup started gaining good weight, had improved activity, reduced urine output even though we have yet to get the dog consistently in the lower 200 blood glucose range. The odd finding is the urine glucose is always negative and we have checked it multiple times. Any explainations or thought? | Have you checked a tli, just to make sure he doesn't have a global pancreatic dysfunction? | The owner can measure accurately and then inject the insulin? |
I would appreciate any imput on a case our practice is working on. We "adopted" a 6 mo old St Ben pup that was extremely thin, had bilateral cataracts, frequent urination etc a month and a half ago. Chem panel revealed the obvious likelyhood of diabetes with blood glucoses running in the 400-500 ranges most of the time. We have been working hard to regulate and pup started gaining good weight, had improved activity, reduced urine output even though we have yet to get the dog consistently in the lower 200 blood glucose range. The odd finding is the urine glucose is always negative and we have checked it multiple times. Any explainations or thought? | What insulin type is he on? | Do his intestines feel very thickened? |
I have a MN of unknown aged cat (used to be ferral until nice people brought him in). He is FIV positive. He develpoed diabetes after an injection of depo medrol for what a vet thought was a flea allergy dermatitis (turns out it was lice). He has been on Lantis for the past 5-6 months and doing ok until 2 weeks ago when he went into DKA. I got him out of this and discovered that he had a UTI. The urine contained nothing but bacteria, unfortunately a culture was not done. He has been doing somewhat ok for the past 2 weeks. His Lantus was increased last week to 5 units BID (he is a 4.3 kg cat). He was in yesterday for a check as the owner had noticed that for the past 3 days his drinking increased to 3-3.5 cups a day, and then had an episode that morning of collapse. Full BW NAF, except elevated BG = 22, urine was positive for ketones. He is still taking zeniquin SID. I let him go home yesterday as he was eating and acting his usual "difficult self".
This morning he got up ate a little and then collapsed on the floor for a morning nap (instead of the chair). His drinking last night had dropped considerably. Electrolytes this am are still normal BG was 19. I got him hooked up to NaCl and KCl at maintanence and started Toronto insulin IM hourly. Well after 7 hours the BG is staying around 18. It dipped to 17.9 but then back up to 18.3.
I just am looking on any advice of where to go with this next. Any suggestions?
I know I am not at max for lantus, but should I be thinking about changing to another insulin? | Are owners able to give insulin appropriately? | What site does the owner use for the bg collection? |
I have a MN of unknown aged cat (used to be ferral until nice people brought him in). He is FIV positive. He develpoed diabetes after an injection of depo medrol for what a vet thought was a flea allergy dermatitis (turns out it was lice). He has been on Lantis for the past 5-6 months and doing ok until 2 weeks ago when he went into DKA. I got him out of this and discovered that he had a UTI. The urine contained nothing but bacteria, unfortunately a culture was not done. He has been doing somewhat ok for the past 2 weeks. His Lantus was increased last week to 5 units BID (he is a 4.3 kg cat). He was in yesterday for a check as the owner had noticed that for the past 3 days his drinking increased to 3-3.5 cups a day, and then had an episode that morning of collapse. Full BW NAF, except elevated BG = 22, urine was positive for ketones. He is still taking zeniquin SID. I let him go home yesterday as he was eating and acting his usual "difficult self".
This morning he got up ate a little and then collapsed on the floor for a morning nap (instead of the chair). His drinking last night had dropped considerably. Electrolytes this am are still normal BG was 19. I got him hooked up to NaCl and KCl at maintanence and started Toronto insulin IM hourly. Well after 7 hours the BG is staying around 18. It dipped to 17.9 but then back up to 18.3.
I just am looking on any advice of where to go with this next. Any suggestions?
I know I am not at max for lantus, but should I be thinking about changing to another insulin? | What diet is this cat eating? | The second stim was unnecessary unless there was a problem with the first one - addison's is something you only need to diagnose once......and you don't monitor it with acth stim tests, so why was the second one done? |
I have a MN of unknown aged cat (used to be ferral until nice people brought him in). He is FIV positive. He develpoed diabetes after an injection of depo medrol for what a vet thought was a flea allergy dermatitis (turns out it was lice). He has been on Lantis for the past 5-6 months and doing ok until 2 weeks ago when he went into DKA. I got him out of this and discovered that he had a UTI. The urine contained nothing but bacteria, unfortunately a culture was not done. He has been doing somewhat ok for the past 2 weeks. His Lantus was increased last week to 5 units BID (he is a 4.3 kg cat). He was in yesterday for a check as the owner had noticed that for the past 3 days his drinking increased to 3-3.5 cups a day, and then had an episode that morning of collapse. Full BW NAF, except elevated BG = 22, urine was positive for ketones. He is still taking zeniquin SID. I let him go home yesterday as he was eating and acting his usual "difficult self".
This morning he got up ate a little and then collapsed on the floor for a morning nap (instead of the chair). His drinking last night had dropped considerably. Electrolytes this am are still normal BG was 19. I got him hooked up to NaCl and KCl at maintanence and started Toronto insulin IM hourly. Well after 7 hours the BG is staying around 18. It dipped to 17.9 but then back up to 18.3.
I just am looking on any advice of where to go with this next. Any suggestions?
I know I am not at max for lantus, but should I be thinking about changing to another insulin? | Is he on a canned low carb, high protein diet? | So sounds like some stressful event triggered the initial visit when the sg was 1.002? |
I have a MN of unknown aged cat (used to be ferral until nice people brought him in). He is FIV positive. He develpoed diabetes after an injection of depo medrol for what a vet thought was a flea allergy dermatitis (turns out it was lice). He has been on Lantis for the past 5-6 months and doing ok until 2 weeks ago when he went into DKA. I got him out of this and discovered that he had a UTI. The urine contained nothing but bacteria, unfortunately a culture was not done. He has been doing somewhat ok for the past 2 weeks. His Lantus was increased last week to 5 units BID (he is a 4.3 kg cat). He was in yesterday for a check as the owner had noticed that for the past 3 days his drinking increased to 3-3.5 cups a day, and then had an episode that morning of collapse. Full BW NAF, except elevated BG = 22, urine was positive for ketones. He is still taking zeniquin SID. I let him go home yesterday as he was eating and acting his usual "difficult self".
This morning he got up ate a little and then collapsed on the floor for a morning nap (instead of the chair). His drinking last night had dropped considerably. Electrolytes this am are still normal BG was 19. I got him hooked up to NaCl and KCl at maintanence and started Toronto insulin IM hourly. Well after 7 hours the BG is staying around 18. It dipped to 17.9 but then back up to 18.3.
I just am looking on any advice of where to go with this next. Any suggestions?
I know I am not at max for lantus, but should I be thinking about changing to another insulin? | What is toronto insulin? | How long after starting insulin was the curve performed? |
I have a MN of unknown aged cat (used to be ferral until nice people brought him in). He is FIV positive. He develpoed diabetes after an injection of depo medrol for what a vet thought was a flea allergy dermatitis (turns out it was lice). He has been on Lantis for the past 5-6 months and doing ok until 2 weeks ago when he went into DKA. I got him out of this and discovered that he had a UTI. The urine contained nothing but bacteria, unfortunately a culture was not done. He has been doing somewhat ok for the past 2 weeks. His Lantus was increased last week to 5 units BID (he is a 4.3 kg cat). He was in yesterday for a check as the owner had noticed that for the past 3 days his drinking increased to 3-3.5 cups a day, and then had an episode that morning of collapse. Full BW NAF, except elevated BG = 22, urine was positive for ketones. He is still taking zeniquin SID. I let him go home yesterday as he was eating and acting his usual "difficult self".
This morning he got up ate a little and then collapsed on the floor for a morning nap (instead of the chair). His drinking last night had dropped considerably. Electrolytes this am are still normal BG was 19. I got him hooked up to NaCl and KCl at maintanence and started Toronto insulin IM hourly. Well after 7 hours the BG is staying around 18. It dipped to 17.9 but then back up to 18.3.
I just am looking on any advice of where to go with this next. Any suggestions?
I know I am not at max for lantus, but should I be thinking about changing to another insulin? | Regular/crystalline insulin? | Is the owner moving the injections around on his body every day? |
Hi,
I have a 13yo DSH diagnosed with Diabetes 18mths ago. Persistent absence of glucosuria led us to taper the 3U BID Glargine he was on down over 3-4mths. We finally stopped insulin after he had been on 1/2U BID for 2months, but the symptoms of DM returned within 4-5 weeks.
We then started him back on Glargine again, increasing the dose from 1 to 2 to 3U BID every 3 weeks, and at 3U BID the polydipsia and glucosuria has resolved.
My question is how to best monitor this cat from here on, do we drop the insulin again if the urine glucose is persistently negative, or we do do occasional curve's in house (cat very easy and stress-free patient), or as some suggest intermittent Fructosamine's?
Thanks!! | Is the cat on a canned food diet? | There are quite a few varieties of cat food in the fresh pet website, anything particular you have in mind? |
Good morning,
I have a patient-14 year old NM DSH named Lucky- who was diagnosed with diabetes mellitus on January 15th of this year.
It was difficult to get this cat to eat canned food at first-we started him on hills md diet b/c he was used to eating k/d diet (another cat with renal disease is on it).
I started him on 1 unit of Glargine BID (he weighed 13.5# at time started insulin- down from 15#. He started to go into remission in mid Feb: alpha trak curve (in clinic, fed at 6AM): 8AM: 71, 10AM: 113, 12 PM: 112, 2PM:
117, 4PM: 140 The alpha trak seems to read low at the low end of normal glucose values)
He was still not having a great appetite, but it was improving, so I thought the low value may have been not enough calories. I kept him on 1 unit BID
For some reason, they didn't return for 2 months. Did a curve in mid April (he had increased urination) He had gotten 1 unit at 6AM after eating (he was 13#)
8AM: 71 on Vet test (46 on AlphaTrak-AT); 10AM: 51 on vet test ( 49 on AT); 12PM: 60 on AT; 2PM: 60 on AT; 4PM: 70 on Vet test(47 on AT)
I decreased to 1/2 unit BID
Curve on 5/20. Cat feels good, eating well, no weakness, normal urination. 1/2 unit given at 5:45: All alpha trak
8AM: 89; 10AM: 96; 12PM: 100; 2PM: 108; 4PM: 113
I decided to leave him on 1/2 unit BID. The curve seemed so good, I didn't want to mess with it. Should I lower him to 1/2 unit daily or wait and recheck a curve in 1 month then decide?
Thank you for your advice on this super nice kitty. | Is this kitty eating well/normally? | Any chance of getting an abdominal ultrasound? |
Good morning,
I have a patient-14 year old NM DSH named Lucky- who was diagnosed with diabetes mellitus on January 15th of this year.
It was difficult to get this cat to eat canned food at first-we started him on hills md diet b/c he was used to eating k/d diet (another cat with renal disease is on it).
I started him on 1 unit of Glargine BID (he weighed 13.5# at time started insulin- down from 15#. He started to go into remission in mid Feb: alpha trak curve (in clinic, fed at 6AM): 8AM: 71, 10AM: 113, 12 PM: 112, 2PM:
117, 4PM: 140 The alpha trak seems to read low at the low end of normal glucose values)
He was still not having a great appetite, but it was improving, so I thought the low value may have been not enough calories. I kept him on 1 unit BID
For some reason, they didn't return for 2 months. Did a curve in mid April (he had increased urination) He had gotten 1 unit at 6AM after eating (he was 13#)
8AM: 71 on Vet test (46 on AlphaTrak-AT); 10AM: 51 on vet test ( 49 on AT); 12PM: 60 on AT; 2PM: 60 on AT; 4PM: 70 on Vet test(47 on AT)
I decreased to 1/2 unit BID
Curve on 5/20. Cat feels good, eating well, no weakness, normal urination. 1/2 unit given at 5:45: All alpha trak
8AM: 89; 10AM: 96; 12PM: 100; 2PM: 108; 4PM: 113
I decided to leave him on 1/2 unit BID. The curve seemed so good, I didn't want to mess with it. Should I lower him to 1/2 unit daily or wait and recheck a curve in 1 month then decide?
Thank you for your advice on this super nice kitty. | Any weight change? | Is he on the cd version of the dm diet? |
14y/o BCS-8+ DSH with FIV and DM has been gaining weight, walking well, and back to normal.
The owner brought in the blood glucose curves which surprised me. | What insulin type is nubby receiving? | I take it nomonitoring is being done? |
14y/o BCS-8+ DSH with FIV and DM has been gaining weight, walking well, and back to normal.
The owner brought in the blood glucose curves which surprised me. | How much is he on? | Translation? |
14y/o BCS-8+ DSH with FIV and DM has been gaining weight, walking well, and back to normal.
The owner brought in the blood glucose curves which surprised me. | What time does he get it? | Do you suspect the dog might have exocrine pancreatic insufficiency secondary to chronic pancreatitis? |
14y/o BCS-8+ DSH with FIV and DM has been gaining weight, walking well, and back to normal.
The owner brought in the blood glucose curves which surprised me. | How long has he had diabetes? | Are you using tail or limb measurements and, if limbs, which one(s)? |
Angel is a 46lb, 10 yr old SF German Shepherd X that I diagnosed with DM back in June of 2012. Was started on Novolin 10.5 units BID (at that time weighed 49lb). Seemed to do well, glucose curve two weeks later was as follows:
O gave insulin and fed at 6am
8am - 88
10am - 101
12pm - 142
2pm - 166
4pm - 318
Told owner to continue at current dose.
October 2012, owner felt like pet was starting to show signs of diabetes again (PU/PD, polyphagia), so brought in for another Glucose curve:
O fed and gave insulin 5am
7:45am - 105
9:45am - 126
11:45am - 157
1:45pm - 217
3:45pm - 309
4:45pm - 343
Continued at 10.5 U Novolin BID
6 month Glucose curve recheck (owner brought back for check because she noticed increase in thirst and pet had accident in the house):
O fed and gave insulin at 5am
8am - 85
10am - 128
12pm - 303
2pm - 375
4pm - 279
So, based on the curves, it appears maybe that the Novolin NPH is wearing off prior to the next dose of insulin. I did a UA and sediment was quiet, but there was glucose in the urine. PE was WNL. My questions are #1 - should I try switching to Detemir or change to another insulin to get a longer duration of action? #2 Does the 3lb weight loss in 1 yr and the glucosuria an indication of poor regulation due to short duration of Novolin? #3 If I need to have her in here to start the curve closer to the time she has her insulin/feeding, will the curve be a good representation if owner switches to say 7am, 7pm schedule for just a few days prior to the curve? Thanks. | Am i correct in assuming the curves end at 4 pm due to hospital hours? | Definitely he needs the insulin...what does his latest bg curve look like? |
I have a 10 year old, CM, DSH that I'm treating for CHF. Diagnosed CHF on 5/21/13 based on history of acute labored breathing and enlarged heart/pulmonary edema based on chest x-rays. At the time a heart arrhythmia was also auscultated. CBC, Chem, electrolytes, T4, UA wnl. The cat is also a diabetic on humalin-N 3U BID - well regulated. He is 14.5 lbs. I started him on 2.5 mg enalapril SID and 12.5mg lasix SID. Re-checked chest x-rays and collected blood pressure yesterday. Chest x-rays indicate improvement in pulmonary edema, however not 100% and systolic blood pressure average was 240. Heart arrhythmia is still present, pulse 150.
I increased lasix to 18.75mg SID and want to start him on cardizem 30mg SID.
My weakness is reading EKGs. Could I have help interpreting this EKG lead II?
Are the circled complexes ventricular in origin?
Is cardizem the right choice?
Should I consider aspirin as well?
Thanks, Dr. | Can you post the chest radiograph? | Not too much pressure here, right? |
I have a patient that I am dearly wishing someone can offer some advice. Inge is an older (I'm at home and don't have access to her file from here) - ~ 10 yo INTACT female Samoyed owned by a client who often likes to do his own thing. About 3 months ago Inge was diagnosed as a diabetic. Her owner is on a limited budget and thus diagnostics have been limited. At her original diagnosis, the client did allow me to perform a urine culture and we treated her for a UTI. I got the owner a glucometer (the same model that we use in clinic - can't remember the name, but designed for dogs/cats) so that the owner can do glucose curves at home to cut down on costs. I am treated Inge with Caninsulin and the owner is feeding a retail brand of food that he has used for several years.
So far her curves have been all over the place. Some of the problems I have narrowed down to the client himself. When I advised the owner to feed Inge two separate meals at insulin time, he doubled the amount of food that he was feeding her, so we cut her back a bit (despite me asking for some of the calorie and feeding info from the bag, the owner manages to forget to bring it in when he comes in to the clinic).
About a month and a half ago, the client decided that the dog needed an "extra" dose of insulin midway through the day. The owner has increased the dose also on his own on certain occasions and only told me after the fact. He runs out of insulin and then rushes in the next morning to pick some up and sooo on.
Fearing somogyi effect, I have had the owner strictly give 10 units of Caninsulin BID, corrected his feeding amounts to the best with the info I have, observed him giving the insulin and reviewed insulin handling. I believe that I'll have problems doing any further diagnostics if I need to with this client. I am concerned that some of the reason why the dog has been so difficult to regulate relates either to the fact that she is an intact female (spaying is out of the question for this owner/dog) or that she has something else going on.... or that perhaps she might require a different insulin.
Here is the most recent glucose curve that I have for Inge from today (10 units BID Caninsulin) with BG readings q 2 hrs approx.
Gave 10 units at 5:30 am , 6 am owner fed 180 gms of food (this is how he measures it out to explain it to me).
6am - 22.8
8am - 17.4
10am - 9.6
12pm - 10.4
2:30pm-31.3 - what the heck? The owner advised that he did not give any food/treats, etc since Inge's morning meal.
4:06pm-29.9
5:45pm - 36.1
I had the owner do a glucose curve in mid-May when she was on 15 units q 12 hrs and these were the results that prompted me to decrease the insulin dose to 10 units (and the above curve) (copy an pasted from his email)
18.5 at 5:58 AM
4.8 at 8AM and I gave her a Milkbone
2.9 at 9AM and I gave her a 1/2 portion of food
5.2 at 10 AM
9.6 at noon
12.0 at 2PM
15.2 4:20PM
17.1 at 6PM
I'm not exactly sure where I should go with this dog/owner combo from here. Is this somogyi effect going on? or is the insulin not lasting long enough and should I consider something else/what else? Diabetic diet?
Looking forward to some of your thoughts/suggestions. | This is really a good time to teach the owner how to generate curves at home---any chance of that? | Why not get an abdominal u/s done? |
Opinions, please? 15 yr old 9kg Rat Terrier, OHE at 9yrs of age, pably nulliparous. Dx'd as DM at 7-8 yrs age, with bilateral cataracts present. Was then managed on Vetsulin until the recall, with no difficulties. Also, diagnosed with 'chronic pancreatitis' via bloodwork only, and was having inconsistent stool quality, at around 9 yrs age; responded to Prozyme alone. Began levothyroxine supplementation around that time, too. Bilateral phacoemulsifications at age 10. Enucleation/implant OS at age 12 secondary to glaucoma. When NPH substituted for Vetsulin was extremely difficult to regulate, several instances of hypoglycemia. I inherited case approximately two years ago, changed diet from low-fat grain-free exclusive to include half amount of normal-carb, had owner add fiber, and switched dog to Levemir, but at 1 unit q12h, she had episodes of hypoglycemia. Glucose curves excellent on 0.5 unit Levemir q12h, and have remained that way since, but with persistent ketonuria. Weight/muscle have been stable. Infrequent episodes of vomiting/diarrhea over past 18 months, respond to conservative therapy. Beginning approximately 14 months ago, signs of cognitive dysfunction or OCD: began with inappropriate urination, neg urine culture, progressing to pacing, altered sleep cycles, etc., over next six months, then stabilized. , and this reduced the pacing . Fructosamine levels have always been in the 300-400 range. Welbutrin trial began two months ago, transient improvement (seemed to begin enjoying being outside again) for a few days, but then regressed in that parameter. Melatonin 3mg BID past week, sleeping better, reduction in pacing after eating, but not before. Urine glucose consistently trace, with marked ketonuria, pH 5.5-6.0. Bloods always wnl except incr glucose and incr triglys, T4 low normal. | Has a glucose curve been done recently? | My q for you is, is the ibd small or large bowel? |
Hi there,
I have some hopefully quick questions regarding management of a diabetic cat who is not responding well to treatment. I have read many of the threats with regards to the same issue but still would like further clarification. "Jeffrey Jefferson Brown" is a 3 yr old MN 4kg Siamese Cross who has been managed as a diabetic since Dec 2012. He initially presented in DKA and had a concurrent triaditis. After very intensive care, we miraculously pulled him through and for the past several months he was being managed well with diet (hills prescription diet m/d -canned) and glargine 1 IU twice daily. However, he has relapsed this month and I am having difficulty trying to regulate his diabetes.
The only significant finding on blood work were mild dehydration (increase in total protein at 84g/), hyperglycemia at 25 mmol/L and slight increase in BUN at 12.6 mmol/L. Creatinine was well within the normal range at 67 umol/L. A urinalysis done in house (by me) revealed an active sediment (an undeniable amount of bacteria from a cystocentesis collection) but the urine culture came back negative. An abdominal u/s revealed a dilated cystic duct, hypoechoic lymph node visible near the greater curvature of the stomach and a slight thickened hypoechoic left limb of the pancreas. The intestines appeared normal.
Jeffrey has a voracious appetite but has lost some weight and along with the slight increase in BUN, the unregulated DM and u/s findings, I am worried about a chronic pancreatitis and possibly IBD. At present, "Jeffrey" is on 3 IU BID, amoxicillin and metronidazole to deal with the suspected UTI (metronidazole is to help with suspected IBD), 250 mcg per week of Vit B12 (owners elected treatment instead of testing due to cost) and Cerenia PO once daily to help with inflammation.
Questions:
1. If we still cannot get Jeffrey's diabetes regulated on 3 IU BID, should I still increase further to 4 IU BID (suggesting resistance at 2 units/kg) or should I add in Leukeran (Chlorambucil) at 2 mg q. 48 hrs? If so, is this a long term or lifelong treatment? How do you determine when we can wean him off? I have never used this drug before.
2. I know it takes weeks for Leukeran to work so should I be adding in Actigall (urosdiol) as well or trying Actigall instead? Is there a rule of thumb as to which one to use first?
3. I read some threads on VIN suggesting that some cats can be managed better on Purina DM canned versus Hills Prescripton diet M/D? Is there any truth to this? Are there any other better options, especially with the possibility of IBD?
Little Jeffrey is only 3 years old and I am hoping to give his the best chance that we can. Thanks so much for your input.
Sincerely, | I presume that there have been no biopsies to definitively diagnose the underlying cellular infiltrates in him, correct? | How much does the dog weigh? |
Hi there,
I have some hopefully quick questions regarding management of a diabetic cat who is not responding well to treatment. I have read many of the threats with regards to the same issue but still would like further clarification. "Jeffrey Jefferson Brown" is a 3 yr old MN 4kg Siamese Cross who has been managed as a diabetic since Dec 2012. He initially presented in DKA and had a concurrent triaditis. After very intensive care, we miraculously pulled him through and for the past several months he was being managed well with diet (hills prescription diet m/d -canned) and glargine 1 IU twice daily. However, he has relapsed this month and I am having difficulty trying to regulate his diabetes.
The only significant finding on blood work were mild dehydration (increase in total protein at 84g/), hyperglycemia at 25 mmol/L and slight increase in BUN at 12.6 mmol/L. Creatinine was well within the normal range at 67 umol/L. A urinalysis done in house (by me) revealed an active sediment (an undeniable amount of bacteria from a cystocentesis collection) but the urine culture came back negative. An abdominal u/s revealed a dilated cystic duct, hypoechoic lymph node visible near the greater curvature of the stomach and a slight thickened hypoechoic left limb of the pancreas. The intestines appeared normal.
Jeffrey has a voracious appetite but has lost some weight and along with the slight increase in BUN, the unregulated DM and u/s findings, I am worried about a chronic pancreatitis and possibly IBD. At present, "Jeffrey" is on 3 IU BID, amoxicillin and metronidazole to deal with the suspected UTI (metronidazole is to help with suspected IBD), 250 mcg per week of Vit B12 (owners elected treatment instead of testing due to cost) and Cerenia PO once daily to help with inflammation.
Questions:
1. If we still cannot get Jeffrey's diabetes regulated on 3 IU BID, should I still increase further to 4 IU BID (suggesting resistance at 2 units/kg) or should I add in Leukeran (Chlorambucil) at 2 mg q. 48 hrs? If so, is this a long term or lifelong treatment? How do you determine when we can wean him off? I have never used this drug before.
2. I know it takes weeks for Leukeran to work so should I be adding in Actigall (urosdiol) as well or trying Actigall instead? Is there a rule of thumb as to which one to use first?
3. I read some threads on VIN suggesting that some cats can be managed better on Purina DM canned versus Hills Prescripton diet M/D? Is there any truth to this? Are there any other better options, especially with the possibility of IBD?
Little Jeffrey is only 3 years old and I am hoping to give his the best chance that we can. Thanks so much for your input.
Sincerely, | Were there wbc's on the urine sediment? | What is the owner doing at home on a daily basis to maintain good oral hygiene? |
10 yo F/S Golden retriever initially presented 5/4/13 for PD (owner did not notice PU) and panting at night only. Everything else normal per owner. Exam: BAR, BCS 8/9, wt 96#. Multiple soft masses noted...previous FNA dx lipoma. Markedly enlarged popliteal LNs and mildly enlarged submanibular LNs. Previously dx seasonal allergies - owner gives benedryl bid EOD which helps.
CBC: WBC 22 x10^9 (rr 6-17), monocytes 0.13 x 10^9 (rr 0.2-1.5), granulocytes 20.28 x 10^9 (rr 3-12)
chem: ALP 694 (rr 20-150), Ca 12.8 (rr 8.6-11.8), GLU 567 (rr 60-110), Na 142 (rr 138-160), K 6.2 (rr 3.7-5.8)
UA via cysto: Glucose 4+, Ketones 1+, Protein 1+, pH 7, USG 1.030
LDDs: Basal cortisol 5.7 (rr1-6.5), 4hr 0.6, 8 hr 5.4...suggestive of PDH Cushings
Dx: DM with concurrent Cushings vs. false positive due to non-adrenal illness
Dog was started on Vetsulin at 22 U BID and diet therapy Hill's W/D
Responded clinically with decreased PD and panting, improved energy and attitude.
Glucose Curve 5/15/13 (dog had been eating 1/2-3/4 offered food - fed 3 cups W/D per feeding) Insulin administrated by owner at home at 6:00 am and then brought into clinic to start curve at 8am
- BG q2h: 48 mg/dl, 54, 63, 64, 75
Decreased Vetsulin to 11 U BID and rechecked BG next day:
BG: 98, 89, 111, 101
Plan stay at current dose of 11 U BID and recheck curve in 7 days. Diet was changed to RCVD diabetic (which dog has been eating better than W/D) There has been no noticeable change in clinical signs since initial response when starting insulin.
5/24/13 BG Curve at 11 U BID: checked q2h: 258 mg/dL, 259, 357, 369
Increased Vetsulin to 15 U BID and rechecked 7 days later
5/31/13: BG 333 mg/dL, 555.
UA: glucose 4+, protein trace, pH 6, USG 1.028
Could this be sigmogyi effect? Potential insulin resistance due to concurrent Cushing's? Not quite sure why this patient responded so dramatically initially to insulin then appears to stop responding. The only change has been diet and the owner has started using a second bottle of vetsulin. Care was taken to instruct owner on proper storage and technique of insulin administration. Any advice on further monitoring parameters to control BG levels? Increase Vetsulin dose? Further diagnositics? Should I begin treatment for Cushing's?
Thank you | Back to the big lymph nodes and elevated calcium....were the nodes aspirated? | Lepto? |
Tori is a spayed female 11 month old Boxer who is thin (see ribs), PU/PD for several months, and has never been house broken. She was born last June and I saw her for her first 3 puppy visits. At the last visit, when I asked about house breaking, it became obvious that their "she is doing great with that" of the last 2 visits was not the case. We checked a urine sample. S.G. was 1.016, and it was loaded with WBCs and rods. We cultured and put her on sulfa trimethoprim based on the sensitivity. We had recommended follow up urine, but they decided to go elsewhere - someone told them this other vet was a Boxer expert and he told them that the labwork I had done was unnecessary and I was just running their bill up. So I did not see Tori again till 2 days ago, as they felt their Boxer expert was not addressing Tori's issues.
On review of the preanesthesia screen the other vet did in February before spaying her, I was concerned that her BUN was mildly elevated 28 (hi N 25) and her creatinine was 1.4(hi N). It made me worry about her kidneys. He had done a UA in April and found nothing, did not culture, but her urine S.G. was 1014. The owner says that she drinks constantly and often vomits up large amounts of water if allowed to empty her bowl. She is a picky eater. We repeated a UA and chem. BUN now 34 with a urine s.g. of 1014, creatinine of 1.4 again, Phosphorous is hi N. I saw nothing in the sediment. We are culturing the urine, there is no protein on the dipstick. Liver enzymes N.
My plan is to send her to a local internist for U/S to check renal architecture especially and another set of brains. Is that the most reasonable next step? Diabetes insipidus is so rare and psychogenic polydipsia is a back into dx. What else would make her so thirsty? The owners limit her drinking at night-she can't go more than 5 hours without urinating. I now wonder if my first low s.g. was due to a renal issue and not simply a UTI-wish I had that follow up UA. Thanks for your help. | How is her vulvar conformation - any hooded vulva noted? | Make sense? |
Tori is a spayed female 11 month old Boxer who is thin (see ribs), PU/PD for several months, and has never been house broken. She was born last June and I saw her for her first 3 puppy visits. At the last visit, when I asked about house breaking, it became obvious that their "she is doing great with that" of the last 2 visits was not the case. We checked a urine sample. S.G. was 1.016, and it was loaded with WBCs and rods. We cultured and put her on sulfa trimethoprim based on the sensitivity. We had recommended follow up urine, but they decided to go elsewhere - someone told them this other vet was a Boxer expert and he told them that the labwork I had done was unnecessary and I was just running their bill up. So I did not see Tori again till 2 days ago, as they felt their Boxer expert was not addressing Tori's issues.
On review of the preanesthesia screen the other vet did in February before spaying her, I was concerned that her BUN was mildly elevated 28 (hi N 25) and her creatinine was 1.4(hi N). It made me worry about her kidneys. He had done a UA in April and found nothing, did not culture, but her urine S.G. was 1014. The owner says that she drinks constantly and often vomits up large amounts of water if allowed to empty her bowl. She is a picky eater. We repeated a UA and chem. BUN now 34 with a urine s.g. of 1014, creatinine of 1.4 again, Phosphorous is hi N. I saw nothing in the sediment. We are culturing the urine, there is no protein on the dipstick. Liver enzymes N.
My plan is to send her to a local internist for U/S to check renal architecture especially and another set of brains. Is that the most reasonable next step? Diabetes insipidus is so rare and psychogenic polydipsia is a back into dx. What else would make her so thirsty? The owners limit her drinking at night-she can't go more than 5 hours without urinating. I now wonder if my first low s.g. was due to a renal issue and not simply a UTI-wish I had that follow up UA. Thanks for your help. | Are we able to get any further information regarding the "never been housebroken" - is she leaking urine while walking around the house/excited, leaving puddles of urine where she is laying, etc etc? | The owner is neither over- nor under-shaking the insulin (we scare them so much sometimes about not over-shaking it that they fail to reconstitute it well and inject diluent); well, since vetsulin came back on the market, the label requires that it be vigorously shaken the first time the bottle is opened, then it should be shaken enough each time it's used to keep it looking continuously milky...is this being done? |
Hi,
I have a 16 year old FS DSH patient whom I have been treating for hyperthyroidism for about a year, it seems to be well controlled based on 3-6 monthly TT4 results. Her management is complicated because she is extremely fractious in the clinic, we have to mask her down with isoflurane to allow any kind of intervention. Her last TT4 (taken about a month ago) was 30.9 (range approx 10-45). At the time this blood sample was taken, the cat had pruritus and scabby lesions around her face, and 20mg depo medrol was given IM. She receives carbimazole 5mg BID.
I've been away from work for 6 weeks, and happened to see her owner at reception, where she mentioned that her cat has been persistently PU/PD since her last visit, and appears ravenous, possibly losing weight but she seems to have a pot belly. She brought in a urine sample yesterday:
USG 1.050
pH 6
Protein 1+
Glucose 4+
I haven't obtained a blood sample yet because the owner is very concerned about how we would manage diabetes in her fractious cat - insulin injections aren't a problem but blood glucose curves are.
I advised the owner that it is very possible that the depo injection tipped her cat over the edge towards diabetes, but that she likely already had some pancreatic pathology/insulin resistance which also played a role. I haven't examined the cat yet, but it doesn't sound like iatrogenic hyperadrenocorticism to me - no history of skin fragility or alopecia.
I understand that the chances of achieving remission in an older cat, even if the depo was a large contributing factor, are reasonable but certainly not guaranteed. I'm also not keen to start insulin therapy without a way of monitoring this cat's response, particularly because I'm worried she will become hypoglycaemic if the depo is a large contributor and starts to wear off.
The owner has asked about oral therapy - I haven't used glipizide before but my understanding is that it could lead to beta cell exhaustion and reduce the chances of permanent remission, and may not be that effective.
I've started the cat on a course of antibiotics for probable UTI.
What would be the best way to manage this case?
☼ | Is the cat nice to the owner at home? | Are you using a high protein low carb diet? |
Hi,
I have a 16 year old FS DSH patient whom I have been treating for hyperthyroidism for about a year, it seems to be well controlled based on 3-6 monthly TT4 results. Her management is complicated because she is extremely fractious in the clinic, we have to mask her down with isoflurane to allow any kind of intervention. Her last TT4 (taken about a month ago) was 30.9 (range approx 10-45). At the time this blood sample was taken, the cat had pruritus and scabby lesions around her face, and 20mg depo medrol was given IM. She receives carbimazole 5mg BID.
I've been away from work for 6 weeks, and happened to see her owner at reception, where she mentioned that her cat has been persistently PU/PD since her last visit, and appears ravenous, possibly losing weight but she seems to have a pot belly. She brought in a urine sample yesterday:
USG 1.050
pH 6
Protein 1+
Glucose 4+
I haven't obtained a blood sample yet because the owner is very concerned about how we would manage diabetes in her fractious cat - insulin injections aren't a problem but blood glucose curves are.
I advised the owner that it is very possible that the depo injection tipped her cat over the edge towards diabetes, but that she likely already had some pancreatic pathology/insulin resistance which also played a role. I haven't examined the cat yet, but it doesn't sound like iatrogenic hyperadrenocorticism to me - no history of skin fragility or alopecia.
I understand that the chances of achieving remission in an older cat, even if the depo was a large contributing factor, are reasonable but certainly not guaranteed. I'm also not keen to start insulin therapy without a way of monitoring this cat's response, particularly because I'm worried she will become hypoglycaemic if the depo is a large contributor and starts to wear off.
The owner has asked about oral therapy - I haven't used glipizide before but my understanding is that it could lead to beta cell exhaustion and reduce the chances of permanent remission, and may not be that effective.
I've started the cat on a course of antibiotics for probable UTI.
What would be the best way to manage this case?
☼ | Perhaps in home testing is an option? | Trucut? |
Hi,
Hoping for some advice on another frustrating ear/skin case. Lucy is a 9 yo F/S Lab mix. Going through her history she has had ear infections 2-3 times a year since she was less than 6 months of age. She also would get occasional bacterial superficial pyodermas and issues with pedal pruritus as well. I can find no obvious seasonal link to her signs based on her chart. Until this year her ear infections were typically yeast.
2 years ago she was diagnosed with diabetes mellitus. She was extremely difficult to regulate and after months of increasing doses of NPH insulin she was changed to detemir insulin and then after a few more months of dose changes she was finally controlled on 15 units BID (she is 70lbs). She has been on w/d diet since her DM diagnosis.
I inherited the case at that point which was about 11 months ago. Since I inherited her we have treated her two times for bacterial pyoderma (7 months ago and 2 months ago). It failed to respond the first time to cephalexin so a culture was done and showed MRSI. It was sensitive to doxycycline and cleared cytologically after 5 wks on doxy and twice weekly chlorhexidine shampoos. The second infection owner declined culture so we empirically treated with doxy and shampooing again and it resolved with 4 weeks of therapy. Owner is doing twice weekly bathing with 4% chlorhexidine containing shampoo for maintanence now.
Also since inheriting her in the last 11 months I have now treated her for three episodes of bacterial otitis externa. The first one was just cocci and responded to Mometomax and routine cleanings. The second one was 4 months later and was rods and cocci - it resolved with Posatex and routine cleanings. Both times we checked cytology prior to stopping meds to confirm resolution. Owner has been cleaning weekly with an ear cleanser for maintanence. I saw her last week for the third episode of otitis which is just cocci now - it has only been 7 weeks since resolution of the last infection.She is back on Posatex right now. Her ears have chronic stenotic changes but no palpable calcification.
In the middle of all this (6 months ago) I diagnosed her with hypothyroidism (she had been gaining weight and on routine BW her cholesterol was elevated, T4 panel showed high TSH, low fT4 and low TT4) and she is currently well controlled on soloxine.
Her diabetes has also been problematic - after we got her T4 disease controlled she went hypoglycemic and after some curves and dose changes we found her insulin requirement had reduced by almost 50% (8 units detemir BID). She was good on this dose for several months but then just last week (when the most recent otitis externa was diagnosed) she was boarding with us and decided to go hypoglycemic again (I was the one feeding her and doing insulin and she was eating normally etc..) so now she is down to 6 units BID and we are curving her again this coming week.
So - that's where I am at right now. I feel like this dog is basically living at our hospital between the skin/ears/DM/thyroid disease and I feel like I am not doing everything I should/could be doing for the skin/ears to try to prevent recurrence.
I know that identifying and addressing a primary cause is what ideally needs to be done. I have had numerous conversations regarding food trials and allergy testing with the owner and he has been reluctant. Given that we only got 7 weeks between the last two ear infections I think he may be starting to come around though. I'll admit that even I am hesitant about a food trial as her DM has been so hard to get a handle on and I would imagine that changing her diet will require more curving and possible insulin adjustments.
Is the food trial where you would start? Preference for which hypoallergenic diet? For long-term medical management of the skin/ears once I get the current infection to clear what would you recommend? I was thinking continuing twice weekly medicated shampoos, weekly ear cleanings and adding in a topical otic steroid twice weekly (this worries me a bit too with her DM but I don't know what else to do). Any recommendations for which otic steroid prep/cleanser/shampoos or any other ideas/thoughts are welcome!
Sorry for the novel and thanks in advance for your time/help :)
/p | Any chance the dog has cushings? | What diet? |
One of my elderly cat patients that has a body score of 5/9 and is only canned food appears to now be diabetic.
Would you recommend an ultrasound to evaluate the pancreas? I put the cat on Zeniquin for the UTI. (Were unable to get a cysto so I did not culture the urine)
BG 326
Fructosamine 489
UA (free catch) SG 1055, glucose 4+, Blood (trace), WBC (10-20), Bacteria (many)
PE below:
S: She has been fine but about 1 month ago started drinking more water. Appetite is good. She seems to be more hungry. No V, D, or Constipation.
O:
WT 8.65 LB
Temp
Gen App Normal
Mm/ crt Normal
Heart Normal
Lungs Normal
Ears Normal
Eyes Normal
Nose Normal
Teeth Severe dental tartar and periodontal disease
Lymph Normal
Skin Normal
Mus/skel Normal
Neuro Normal
Hydration Normal
Abd/palp Normal
Thyroid Normal
Vaccines Given/Treatments/Tests:
GDT4
BP 140, 140, 140, 150, 150
A: (Problem list)
Dental dx
P: Email with results | What canned diets is this kitty eating? | Should i worry about anesthesia at this time? |
Hi
I was just looking for some help in a case I am currently trying to work through as it has me a bit stumped.
Female speyed 9 year old DSH originally presented to the clinic about 2 years ago for lameness in her right forelimb (before I worked at the clinic). No other abnormalities were found on examination. Radiographs of the limb were taken and were found to be normal. Home with antiinflammatories for presumed soft tissue injury as source of the lameness.
She then represented to me this time about a year ago for the same problem. Owner reports that the lameness may of improved a little on the medication but that in general the lameness tends to come and go especially in regards to how severe it is. On clinical examination she was found to have a palmar grade gait in the right forelimb (carpus touching the ground as she walked). Additionally the foot was splayed laterally at the level of the carpus. There was no pain on palpation of any part of the limb and she walked around the consult normally despite the angle of her forelimb. Remainder of the examination was normal, including neurological work up. I reassessed the previous radiograph taken and like the previous vet could find nothing wrong and so explained this to the owner and told him to come back in if the cat got worse or became painful in any way.
The same cat has now represented for a third time last Friday, however now the problem seems to of progressed. She now has a palmar grade gait in both forelimbs with the left worse than the right as of the examination, and she has a plantigrade gait in her hind limbs, she is also now ataxic and had a narrow base stance esp in the hind limbs. CN all normal. Proprioception and postural reflexes normal in all 4. Normal hindlimb reflexes, and withdrawl in all 4 (could not elicit forelimb reflexes - but maybe due to technique). Normal pain perception in all 4 From this presentation I believed she probably had Diabetes and this was diabetic polyneuropathy so suggested blood work to confirm.
CBC
Hb - 129 (80-140)
hct - 0.41 (0.28-0.45)
MCV - 56 (40-52) HIGH
MCH - 18 (13-18)
WBC - 3.8 (6-16) LOW
neut - 2.6 (3.8-10.1) LOW
lymp - 0.9 (1.6-7.0) LOW
mono - 0.2 (0.6)
eos - 0.1 (1.4)
Baso - 0.0 (0.2)
RBC - anisocytosis
WBC - leucopenia, neutropenia, lymphopenia
Platelets normal
Biochemistry
sodium - 153mmol/L (147-161)
Potassium - 4.4 mmol/L (3.7-4.9)
Chloride - 118 mmol/L (100-125)
Bicarb - 17mmol/L (15-24)
anion gap 22mmol/L
urea - 10.5 mmol/L (3-10) MARGINALLY HIGH
creatinine - 115umol/L (40-190)
glucose - 7.9mmol/L (3.9-8.3) (in house blood glucose done as well which was 8.2mmol/L)
Bilirubin - 1umol/L (17)
AST - 39 U/L (1-60)
ALT - 86 U/L (1-80) HIGH
ALP - 44 U/L (81)
Protein - 74 g/L (55-78)
albumin - 40 g/L (22-35) HIGH
Globulin - 34 g/L (33-43)
A/G ratio - 1.2
Calcium - 2.44mmol/L (1.9-2.7)
phosphate - 1.11mmol/L (1.00-2.00)
CK - 105 U/L (261)
Cholesterol - 3.5 mmol/L (2.4-5.2)
Triglyceride - 0.6mmol/L (0.1-0.6)
T4 - 24 nmol/L (6-52)
Based on these results I presume DM neuropathy is not the cause of the signs I am seeing. From reading about other similar cases on VIN today I was now wondering about toxo, FIV and other neuropathies that maybe the cause. Spoke to the owner this afternoon and the cat is about the same as friday, is BAR and eating well but oddly has not defaecated for 3 days now (dont know if this is significant/related to the progression of the neurological signs).
If anyone has some ideas of what may be going on here I would love to hear what you have to say or any ideas of what I could do next, it would be greatly appreciated.
Thanks ☼ | Has this cat been recently tested for felv/fiv? | So did the cortisols at the end of induction come into that range? |
Hi
I was just looking for some help in a case I am currently trying to work through as it has me a bit stumped.
Female speyed 9 year old DSH originally presented to the clinic about 2 years ago for lameness in her right forelimb (before I worked at the clinic). No other abnormalities were found on examination. Radiographs of the limb were taken and were found to be normal. Home with antiinflammatories for presumed soft tissue injury as source of the lameness.
She then represented to me this time about a year ago for the same problem. Owner reports that the lameness may of improved a little on the medication but that in general the lameness tends to come and go especially in regards to how severe it is. On clinical examination she was found to have a palmar grade gait in the right forelimb (carpus touching the ground as she walked). Additionally the foot was splayed laterally at the level of the carpus. There was no pain on palpation of any part of the limb and she walked around the consult normally despite the angle of her forelimb. Remainder of the examination was normal, including neurological work up. I reassessed the previous radiograph taken and like the previous vet could find nothing wrong and so explained this to the owner and told him to come back in if the cat got worse or became painful in any way.
The same cat has now represented for a third time last Friday, however now the problem seems to of progressed. She now has a palmar grade gait in both forelimbs with the left worse than the right as of the examination, and she has a plantigrade gait in her hind limbs, she is also now ataxic and had a narrow base stance esp in the hind limbs. CN all normal. Proprioception and postural reflexes normal in all 4. Normal hindlimb reflexes, and withdrawl in all 4 (could not elicit forelimb reflexes - but maybe due to technique). Normal pain perception in all 4 From this presentation I believed she probably had Diabetes and this was diabetic polyneuropathy so suggested blood work to confirm.
CBC
Hb - 129 (80-140)
hct - 0.41 (0.28-0.45)
MCV - 56 (40-52) HIGH
MCH - 18 (13-18)
WBC - 3.8 (6-16) LOW
neut - 2.6 (3.8-10.1) LOW
lymp - 0.9 (1.6-7.0) LOW
mono - 0.2 (0.6)
eos - 0.1 (1.4)
Baso - 0.0 (0.2)
RBC - anisocytosis
WBC - leucopenia, neutropenia, lymphopenia
Platelets normal
Biochemistry
sodium - 153mmol/L (147-161)
Potassium - 4.4 mmol/L (3.7-4.9)
Chloride - 118 mmol/L (100-125)
Bicarb - 17mmol/L (15-24)
anion gap 22mmol/L
urea - 10.5 mmol/L (3-10) MARGINALLY HIGH
creatinine - 115umol/L (40-190)
glucose - 7.9mmol/L (3.9-8.3) (in house blood glucose done as well which was 8.2mmol/L)
Bilirubin - 1umol/L (17)
AST - 39 U/L (1-60)
ALT - 86 U/L (1-80) HIGH
ALP - 44 U/L (81)
Protein - 74 g/L (55-78)
albumin - 40 g/L (22-35) HIGH
Globulin - 34 g/L (33-43)
A/G ratio - 1.2
Calcium - 2.44mmol/L (1.9-2.7)
phosphate - 1.11mmol/L (1.00-2.00)
CK - 105 U/L (261)
Cholesterol - 3.5 mmol/L (2.4-5.2)
Triglyceride - 0.6mmol/L (0.1-0.6)
T4 - 24 nmol/L (6-52)
Based on these results I presume DM neuropathy is not the cause of the signs I am seeing. From reading about other similar cases on VIN today I was now wondering about toxo, FIV and other neuropathies that maybe the cause. Spoke to the owner this afternoon and the cat is about the same as friday, is BAR and eating well but oddly has not defaecated for 3 days now (dont know if this is significant/related to the progression of the neurological signs).
If anyone has some ideas of what may be going on here I would love to hear what you have to say or any ideas of what I could do next, it would be greatly appreciated.
Thanks ☼ | Any chance you could post a video of this kitty walking? | What steroid did he get? |
Brandy is a 5yo Pitbull mix presented for being PU/PD. PE wnl. CBC/Chem wnl except for a PCV 64 and TP 7. Urine in house wnl, except for a very low USG = 1.003. Among other diseases, decided to focus on DI as the pet does not show any clear evident clinical signs for other diseases that cause PU/PD. Performed a water deprivation test in 10hrs (o cannot afford anything else).
Baseline USG = 1.004 (PCV 62% and TP 7g/dl)
@ 2hrs - USG = 1.012
@ 6hrs - USG = 1.014
@ 10hrs USG = 1.018.
I know that the way the test was performed was not ideal, but should I continue to pursue DI as the potential underlying cause of this dog's PU/PD? Let me know your opinion.
Thanks! | I don't think you have lepto there, right? | What is this kitty's weight currently and what (and how much) is he eating? |
Last week I saw a 4 YO neutered male cat with a 1 year history of trembling and standing and walking with a plantigrade stance. His owner wanted to have him checked for diabetes. On physical exam he had full body tremors, a prominent spine, hind limb weakness and was walking on his hocks. Otherwise his exam was fairly normal. The only abnormalities on bloodwork were creatinine 0.4mg/DL(0.6-2.4), amylase1402U/L(100-1200), CPK 714U/L(56-529), and platelets 135. (200-500). T4 and ft also normal. Urine was not available. Blood glucose was 100mg/DL(64-170). The owner had given BIM something called methyl B12 that she found on the internet for peripheral neuropathy. She thought that it had decreased the trembling some but had stopped it with no increase to the previous level of trembling. What else should I offer her before referral to a neurologist or IM specialist?
Thanks for any advice that you can give me. ☼ | Is the plantigrade stance bilateral? | Are you sure it's vomiting and not regurgitation? |
Last week I saw a 4 YO neutered male cat with a 1 year history of trembling and standing and walking with a plantigrade stance. His owner wanted to have him checked for diabetes. On physical exam he had full body tremors, a prominent spine, hind limb weakness and was walking on his hocks. Otherwise his exam was fairly normal. The only abnormalities on bloodwork were creatinine 0.4mg/DL(0.6-2.4), amylase1402U/L(100-1200), CPK 714U/L(56-529), and platelets 135. (200-500). T4 and ft also normal. Urine was not available. Blood glucose was 100mg/DL(64-170). The owner had given BIM something called methyl B12 that she found on the internet for peripheral neuropathy. She thought that it had decreased the trembling some but had stopped it with no increase to the previous level of trembling. What else should I offer her before referral to a neurologist or IM specialist?
Thanks for any advice that you can give me. ☼ | Were you able to do spinal rads, as well as those of the thorax and abdomen? | Was insulin dose 0.5 unit/kg? |
Last week I saw a 4 YO neutered male cat with a 1 year history of trembling and standing and walking with a plantigrade stance. His owner wanted to have him checked for diabetes. On physical exam he had full body tremors, a prominent spine, hind limb weakness and was walking on his hocks. Otherwise his exam was fairly normal. The only abnormalities on bloodwork were creatinine 0.4mg/DL(0.6-2.4), amylase1402U/L(100-1200), CPK 714U/L(56-529), and platelets 135. (200-500). T4 and ft also normal. Urine was not available. Blood glucose was 100mg/DL(64-170). The owner had given BIM something called methyl B12 that she found on the internet for peripheral neuropathy. She thought that it had decreased the trembling some but had stopped it with no increase to the previous level of trembling. What else should I offer her before referral to a neurologist or IM specialist?
Thanks for any advice that you can give me. ☼ | Retrovirus status? | Is this kitty a cheek chewer? |
Katie is an 11yr old FeS DSH that I have been treating for idiopathic hypercalcemia since Feb 2010. Treatment has been oral prednisolone tapered to 1mg/kg BID. Higher doses induced transient diabetes mellitus. The owner is a dentist and wil not consider bisphosphonates.
She has 2 infected maxillary premolars that I think need extracted.
Chem profile WNL except:
Alb Hi at 4.1(2.5-3.9)
Ca Hi @ 11.7 (8.2-10.8)
Trig Hi @ 327 (25-160)
CaP = 42
Please comment on anesthesia safety and induct4ion drug protocol.
Thank you very much!! ☼ | What is your normal anesthetic protocol for a cat like this? | How long after premeds did you induce? |
Good Morning,
I have a Physician client with a diabetic female Dachshund. They have been performing Glucose Curves at home with relatively good success. The owner recently advised me that she had decided to give a higher dose in the AM than she gives in the PM [6units AM/5 units PM] since she felt that the dog felt better? She did this because she had noted that the AM pre-dose glucose was slightly lower than the PM pre-dose level. This did not really 'bother' me.
I have always given similar doses for morning and evening. Is there any logic to giving different doses for NPH insulin?
Thanks, br/
☼ | Is the dog a spayed female or intact? | The owner can accurately measure and then inject the insulin each time? |
I recently took over the management of a diabetic cat (~10-12 years old, ~ 15 pounds) on 5/10/2013 when the pet presented to me after having a seizure. The cat was diagnosed as diabetic in 2010 and the owner reported that normal routine was followed with feeding the cat and administering the insulin (glargine 8U q12h) to only have the cat have a seizure ~ 20-30 minutes later. The owner administered coca cola via a syringe to improve blood glucose levels (I've made recommendations to use alternative to coca cola in future) and by the time I saw the cat, BG was 628 (yikes!!). Since this initial presentation, I've done 2 glucose curves and have a few questions regarding where to go from here with attempting to regulate this cat (this is my first experience with glargine).
The first curve I did was on 5/19 (8U q12h):
7a (fasting sample) - 512
9a - 500
11a - 464
1p - 135
3p - 63
4p - 363
5p - 439
partial U/A: Glu > 1000, neg ketones
--> recommended decreasing insulin dosage to 4U q12h, stressed need to get pet off dry DM and have him eating only wet DM or other low carb wet food, stgly encouraged owner to purchase glucometer glucose curves can be done at home while trying to regulate cat
Second curve 5/31 with hospital AlphaTrak and owner's new glucometer (4U q12h):
AlphaTrak
5p (fasting sample) - 313
7p (fed but no insulin) - 340
*error with protocol so cat fed at ~6-6:30p but no insulin administered until after 7p glucose check
9p - 413
11p - 313
1a - 403
3a - 391
5a - 341
Owner's glucometer
5p (fasting sample) - 476
7p (fed but no insulin) - 410
9p - 469
11p - 445
1a - 436
3a - 425
5a - 366
So my questions include:
- Owner draws up insulin into syringe night before and keeps syringes in refrigerator until use. Is there any contraindications to this?
- Based on the recent curve, I'm inclined to increase dosage to 5U q12h... thoughts?
- Any thoughts regarding how the AlphaTrak results from recent curve seem to undulate whereas the human glucometer is a smoother curve? Could the amount of alcohol placed on the ear have an effect (like dilution)? I found out techs completely saturating the ear and wasn't sure if this could be related... (the human glucometer requires much less blood compared to the AlphaTrak so might relate somehow?).
- Cat has moderate gingivitis associated with mild dental calculus and suspect FORLs. Will this have a major impact on regulation? I know dental disease can impact regulation, but wasn't sure at what severity dental disease will actually have an impact.
- I'm also concerned about history of increasing proteinuria (200-300 beginning 11/2012, 500 on 2/2013) as possible consequence of past 1.5 years of being unregulated (my interpretation of history) or beginning of renal disease. Any recommendations regarding work-up and management of proteinuria with diabetic?
__________________________
History (in case you want it...):
1/4/2010 - initial presentation to clinic for mass removal from right nasal area, no histopathology - pre-op labs show BG 226 (ref range 70-150)
11/26/2010 - presented for polyphagia, weight loss, PU/PD, vomiting
Labs - UA: Glucose > 1000, 1+ ketones, Chem: Glu 577 (70-150), T4 0.5 (0.8-4.7), BUN 33 (10-30), Crea 1.0 (0.3-2.1)
-->Glargine started at 2 units q12h, started P on canned DM
12/18/2010 - BG curve (2U q12h)
8:45a (Fasting sample) - 127
10a - 190
12p - 144
2p - 107
5p - 122
-->no change in insulin dosage
2/19/2011 - Fructosamine (2U q12h)
353 (191-349)
--> no change in insulin dosage
3/26/2011 - Fructosamine (2U q12h)
243 (191-349)
--> thought to possibly going into remission, dosage deceased to 1U q12h
4/16/2011 - BG curve (1U q12h)
8:30a (fasting sample) - 195
10a - 217
12p - 127
2p - 100
4p - 109
5p - 156
--> no change to insulin dosage
5/21/2011 - Fructosamine (1U q12h)
273 (191-349)
-->discontinued insulin
10/22/2011 - presented for weight loss, PU/PD of 2 month duration, P no longer eating canned DM, only dry DM
Labs - U/A: Glu > 1000, neg ketones; Chem: Glu 549, T4 1.7 (0.8-4.7); Urine culture: no growth
--> restarted glargine at 2U q12h
11/19/2011 - presented for assessment of PU/PD and bite wound (2U q12h)
Glu 623
--> increased dosage to 4U q12h
1/9/2012 - Fructosamine and BG (4U q12h)
Fructosamine 470 (191-349)
BG 687
--> increased dosage to 5U q12h
1/21/2012 - Glucose curve (5U q12h)
8am (fasting sample) - 599
10a - 588
12p - 538
2p - 428
4p - 416
UA: Glu > 1000, no ketones
--> increased dosage to 7U q12h
2/11/2012 - spot check (7U q12h)
BG 600
--> continue 7U q12h
2/25/2012 - Fructosamine (7U q12h)
348 (191-348)
--> continue 7U q12h
5/12/2012 - Fructosamine (7U q12h)
356 (191-349)
--> continue 7U q12h
11/24/2012 - Annual exam (7U q12h)
BG 498
Fructosamine 367 (191-349)
T4 1.1 (0.8-4.7)
BUN 50 (15-34)
Crea normal (sorry didn't write down this value)
U/A: Glu > 1000, neg ketone, protein 200-300 (verified with SSA), USG 1.031
--> increase insulin dosage to 8U q12h, recommended weight loss, discussed dental due to FORLs
2/15/2013 - Fructosamine (8U q12h)
348 (191-349)
U/A: Glu > 1000, neg ketone, protein 500
--> continue 8U q12h, recommended dental
3/9/2013 - pre-anesthetic labs for possible dental (8U q12h)
Glu 648, HCT 48%, BUN 43 (15-34), Crea 1.6 (0.8-2.3)
--> continue 8U q12h, questioned owner why glucose would be high and possible dehydration | How old is the bottle of insulin? | Vetsulin should be vigorously shaken the first time the bottle is opened, then should be shaken enough each time it's used to keep it looking continuously milky...is this being done? |
Daisy is a 13 yr old FS DSH. In sept 2011 she had lower urinary tract disease signs but on exam a large abdominal mass was found. The mass turned out to be a large hairball in the stomach. The owner had not noted any GI signs at that time. She presented again in Aug 2012 for not eating and retching but nothing comes up. The stomach felt distended again and another hairball was found on exploratory. I'm not sure why samples of stomach and intestines were not taken at that time the owner may have declined it. She presented again on 5/28/13 and owner supsected hairball again. This time she was not eating well, gaging some and just lethargic. Again another hairball was removed and this time samples of stomach and SI were submitted for histopath (see below). For the most part she does not display any GI signs inbetween episodes only for a few days before presentation. The says she will occassionally vomit but not frequently.
My question is if I should start her on prednisone or try Atopica. From what I have read patients with eosinophilic enteritis need high doses of pred and usually become diabetic. I would like to try Atopica instead but since she doesn't show many GI signs I worry if we will be able to tell if it is working or not or will we have to wait another 6-8 months to see if she gets another hairball. Also according to the histopath lymphoma is possible so maybe I shouldn't use Atopica at all. I was also going to start Vit B injections. We have not done a Cobalamin, TLI or folate test yet. Money is an issue so I don't know if the owner will let us.
Thanks
☼ | Is there weight loss? | Is anything else happening during these pupd spells that might be triggering a behavioral component? |
Pepper is a 15# 8 yo F/S DSH who presented for "ADR" in 2/13- blood work revealed a BG of 546, other wise wnl. u/a was 3+ glucose, 3+ blood. My colleague contacted the owner and started Pepper on Glargine 3U BID (she was 13.5#- so I think this is a. 0.5U/kg dose). We did a curve about 3 weeks later (q2h for as many as we can during office hours- o declined home- testing).
8a- 316 10a- 392 12p- 414 2p- 392
Glargine was raised to 3.5U BID then BG was repeated 5w later
8a- 328 10a- 295 12p- 250 2p- 246
We increased to 4U bid and repeated the curve 5/14
8a- 339 10a- 278 12p- 283 2p- 271 4p- 256
A fructosamine was done a few days ago- 551mmol/L
Clinically the patient is doing very well, more affectionate, less pu/pd. There are no notes in the records about what the cat is eating but it was discussed to give a diabetic diet.
I am not sure if I should keep the pet on this dose, is it too high? Looking at the curve, it could be as it is rather flat, but the fructoamine is high. I will reapproach diet when I talk to the owner... but are we on the right track or are we totally off base? It seems like opinions differ... thanks for your help!
☼ | Has the cat been losing weight, or gaining weight? | Do you have a ua? |
Pepper is a 15# 8 yo F/S DSH who presented for "ADR" in 2/13- blood work revealed a BG of 546, other wise wnl. u/a was 3+ glucose, 3+ blood. My colleague contacted the owner and started Pepper on Glargine 3U BID (she was 13.5#- so I think this is a. 0.5U/kg dose). We did a curve about 3 weeks later (q2h for as many as we can during office hours- o declined home- testing).
8a- 316 10a- 392 12p- 414 2p- 392
Glargine was raised to 3.5U BID then BG was repeated 5w later
8a- 328 10a- 295 12p- 250 2p- 246
We increased to 4U bid and repeated the curve 5/14
8a- 339 10a- 278 12p- 283 2p- 271 4p- 256
A fructosamine was done a few days ago- 551mmol/L
Clinically the patient is doing very well, more affectionate, less pu/pd. There are no notes in the records about what the cat is eating but it was discussed to give a diabetic diet.
I am not sure if I should keep the pet on this dose, is it too high? Looking at the curve, it could be as it is rather flat, but the fructoamine is high. I will reapproach diet when I talk to the owner... but are we on the right track or are we totally off base? It seems like opinions differ... thanks for your help!
☼ | Was she an overweight cat to begin with? | What dose and for how long was the metronidazole used? |
Pepper is a 15# 8 yo F/S DSH who presented for "ADR" in 2/13- blood work revealed a BG of 546, other wise wnl. u/a was 3+ glucose, 3+ blood. My colleague contacted the owner and started Pepper on Glargine 3U BID (she was 13.5#- so I think this is a. 0.5U/kg dose). We did a curve about 3 weeks later (q2h for as many as we can during office hours- o declined home- testing).
8a- 316 10a- 392 12p- 414 2p- 392
Glargine was raised to 3.5U BID then BG was repeated 5w later
8a- 328 10a- 295 12p- 250 2p- 246
We increased to 4U bid and repeated the curve 5/14
8a- 339 10a- 278 12p- 283 2p- 271 4p- 256
A fructosamine was done a few days ago- 551mmol/L
Clinically the patient is doing very well, more affectionate, less pu/pd. There are no notes in the records about what the cat is eating but it was discussed to give a diabetic diet.
I am not sure if I should keep the pet on this dose, is it too high? Looking at the curve, it could be as it is rather flat, but the fructoamine is high. I will reapproach diet when I talk to the owner... but are we on the right track or are we totally off base? It seems like opinions differ... thanks for your help!
☼ | Has a urine culture been checked yet? | Is there a possibliity that the client is having a problem pilling this patient? |
Pepper is a 15# 8 yo F/S DSH who presented for "ADR" in 2/13- blood work revealed a BG of 546, other wise wnl. u/a was 3+ glucose, 3+ blood. My colleague contacted the owner and started Pepper on Glargine 3U BID (she was 13.5#- so I think this is a. 0.5U/kg dose). We did a curve about 3 weeks later (q2h for as many as we can during office hours- o declined home- testing).
8a- 316 10a- 392 12p- 414 2p- 392
Glargine was raised to 3.5U BID then BG was repeated 5w later
8a- 328 10a- 295 12p- 250 2p- 246
We increased to 4U bid and repeated the curve 5/14
8a- 339 10a- 278 12p- 283 2p- 271 4p- 256
A fructosamine was done a few days ago- 551mmol/L
Clinically the patient is doing very well, more affectionate, less pu/pd. There are no notes in the records about what the cat is eating but it was discussed to give a diabetic diet.
I am not sure if I should keep the pet on this dose, is it too high? Looking at the curve, it could be as it is rather flat, but the fructoamine is high. I will reapproach diet when I talk to the owner... but are we on the right track or are we totally off base? It seems like opinions differ... thanks for your help!
☼ | Considering other causes of a relative insulin resistance/poor response such as hyperadrenocorticism, acromegaly, pancreatitis, uti, improper insulin injection technique (is the owner using the pen or the 10-ml vial? | (can you add the signalment? |
Hi,
Wasn't sure where to post this, but decided to start here. "Escher" is an approximately 9 y.o. (though I'm starting to suspect older) dsh who became diabetic in the span of one week in 11/11 (normal bloodwork one week, diabetic the next). This was preceded by a brief, ADR episode. Urine specific gravity at the time was 1.038. She was started on glargine and DM diet. She is not a canned food fan, but loves the dry.
She had a nice response to the glargine, though the owner continued to report PU/PD. A month after diagnosis, the owner brought in a contaminated urine sample that appeared to have a USG of 1.012. The BUN, which was 22 at the time of diagnosis, was now 61, which I attributed to the DM diet. Creatinine was 1.6 both times.
We were able to get Escher off insulin about 4 months after diagnosis, but 7 months later, she relapsed. She did continue to eat primarily dry DM during this time. BUN at time of relapse was 81, creatinine 2.5. Two weeks later, her BUN was 59, creatinine 2.0.
Without boring you with the details, Escher has been a little harder to regulate this time, but has generally been doing well. Mom is great, but sometimes a difficult historian as far as how Escher is truly doing. She has consistently reported PU/PD, even when her blood sugars have looked pretty good (I will admit we don't do a lot of curves, but tend to spot check; for the most part Escher has maintained weight throughout this period).
Anyway, her most recent bloodwork showed a BUN of 81, creatinine of 2.2, and a USG of 1.018. My question is, do we expect these changes in BUN and USG from a cat on DM diet? Both numbers were fairly normal at diagnosis, but within a month appear to have changed. If we feel that the decrease in USG represents a loss of concentrating ability due to renal disease, when do we get uncomfortable with the elevation in BUN? Her creatinine has crept up, but is still technically in the normal range at Antech. I feel that the DM has helped us with this cat's diabetic regulation, so I am reluctant to take her off it, yet I do not want to overload "challenged" kidneys. Interestingly, even with the elevation of BUN and dilute urine, the owner feels that Escher's PU/PD is significantly improved from the past (her sugars have been running lower lately--in fact a little too low for my liking). In general, even in a normal cat, is there a point where the BUN is too high when on a higher protein/lower carb diet?
Thanks in advance for your help.
/p | Can you palpate her kidneys? | Is the cat diabetic? |
Hi,
Wasn't sure where to post this, but decided to start here. "Escher" is an approximately 9 y.o. (though I'm starting to suspect older) dsh who became diabetic in the span of one week in 11/11 (normal bloodwork one week, diabetic the next). This was preceded by a brief, ADR episode. Urine specific gravity at the time was 1.038. She was started on glargine and DM diet. She is not a canned food fan, but loves the dry.
She had a nice response to the glargine, though the owner continued to report PU/PD. A month after diagnosis, the owner brought in a contaminated urine sample that appeared to have a USG of 1.012. The BUN, which was 22 at the time of diagnosis, was now 61, which I attributed to the DM diet. Creatinine was 1.6 both times.
We were able to get Escher off insulin about 4 months after diagnosis, but 7 months later, she relapsed. She did continue to eat primarily dry DM during this time. BUN at time of relapse was 81, creatinine 2.5. Two weeks later, her BUN was 59, creatinine 2.0.
Without boring you with the details, Escher has been a little harder to regulate this time, but has generally been doing well. Mom is great, but sometimes a difficult historian as far as how Escher is truly doing. She has consistently reported PU/PD, even when her blood sugars have looked pretty good (I will admit we don't do a lot of curves, but tend to spot check; for the most part Escher has maintained weight throughout this period).
Anyway, her most recent bloodwork showed a BUN of 81, creatinine of 2.2, and a USG of 1.018. My question is, do we expect these changes in BUN and USG from a cat on DM diet? Both numbers were fairly normal at diagnosis, but within a month appear to have changed. If we feel that the decrease in USG represents a loss of concentrating ability due to renal disease, when do we get uncomfortable with the elevation in BUN? Her creatinine has crept up, but is still technically in the normal range at Antech. I feel that the DM has helped us with this cat's diabetic regulation, so I am reluctant to take her off it, yet I do not want to overload "challenged" kidneys. Interestingly, even with the elevation of BUN and dilute urine, the owner feels that Escher's PU/PD is significantly improved from the past (her sugars have been running lower lately--in fact a little too low for my liking). In general, even in a normal cat, is there a point where the BUN is too high when on a higher protein/lower carb diet?
Thanks in advance for your help.
/p | If they are normal in size, then we need to do more looking into what's happening e.g. could there be a hydration problem? | How long was the cat fasted before the blood sample was drawn? |
Hi,
Wasn't sure where to post this, but decided to start here. "Escher" is an approximately 9 y.o. (though I'm starting to suspect older) dsh who became diabetic in the span of one week in 11/11 (normal bloodwork one week, diabetic the next). This was preceded by a brief, ADR episode. Urine specific gravity at the time was 1.038. She was started on glargine and DM diet. She is not a canned food fan, but loves the dry.
She had a nice response to the glargine, though the owner continued to report PU/PD. A month after diagnosis, the owner brought in a contaminated urine sample that appeared to have a USG of 1.012. The BUN, which was 22 at the time of diagnosis, was now 61, which I attributed to the DM diet. Creatinine was 1.6 both times.
We were able to get Escher off insulin about 4 months after diagnosis, but 7 months later, she relapsed. She did continue to eat primarily dry DM during this time. BUN at time of relapse was 81, creatinine 2.5. Two weeks later, her BUN was 59, creatinine 2.0.
Without boring you with the details, Escher has been a little harder to regulate this time, but has generally been doing well. Mom is great, but sometimes a difficult historian as far as how Escher is truly doing. She has consistently reported PU/PD, even when her blood sugars have looked pretty good (I will admit we don't do a lot of curves, but tend to spot check; for the most part Escher has maintained weight throughout this period).
Anyway, her most recent bloodwork showed a BUN of 81, creatinine of 2.2, and a USG of 1.018. My question is, do we expect these changes in BUN and USG from a cat on DM diet? Both numbers were fairly normal at diagnosis, but within a month appear to have changed. If we feel that the decrease in USG represents a loss of concentrating ability due to renal disease, when do we get uncomfortable with the elevation in BUN? Her creatinine has crept up, but is still technically in the normal range at Antech. I feel that the DM has helped us with this cat's diabetic regulation, so I am reluctant to take her off it, yet I do not want to overload "challenged" kidneys. Interestingly, even with the elevation of BUN and dilute urine, the owner feels that Escher's PU/PD is significantly improved from the past (her sugars have been running lower lately--in fact a little too low for my liking). In general, even in a normal cat, is there a point where the BUN is too high when on a higher protein/lower carb diet?
Thanks in advance for your help.
/p | Pyelonephritis? | What's his bcs? |
Hi,
Wasn't sure where to post this, but decided to start here. "Escher" is an approximately 9 y.o. (though I'm starting to suspect older) dsh who became diabetic in the span of one week in 11/11 (normal bloodwork one week, diabetic the next). This was preceded by a brief, ADR episode. Urine specific gravity at the time was 1.038. She was started on glargine and DM diet. She is not a canned food fan, but loves the dry.
She had a nice response to the glargine, though the owner continued to report PU/PD. A month after diagnosis, the owner brought in a contaminated urine sample that appeared to have a USG of 1.012. The BUN, which was 22 at the time of diagnosis, was now 61, which I attributed to the DM diet. Creatinine was 1.6 both times.
We were able to get Escher off insulin about 4 months after diagnosis, but 7 months later, she relapsed. She did continue to eat primarily dry DM during this time. BUN at time of relapse was 81, creatinine 2.5. Two weeks later, her BUN was 59, creatinine 2.0.
Without boring you with the details, Escher has been a little harder to regulate this time, but has generally been doing well. Mom is great, but sometimes a difficult historian as far as how Escher is truly doing. She has consistently reported PU/PD, even when her blood sugars have looked pretty good (I will admit we don't do a lot of curves, but tend to spot check; for the most part Escher has maintained weight throughout this period).
Anyway, her most recent bloodwork showed a BUN of 81, creatinine of 2.2, and a USG of 1.018. My question is, do we expect these changes in BUN and USG from a cat on DM diet? Both numbers were fairly normal at diagnosis, but within a month appear to have changed. If we feel that the decrease in USG represents a loss of concentrating ability due to renal disease, when do we get uncomfortable with the elevation in BUN? Her creatinine has crept up, but is still technically in the normal range at Antech. I feel that the DM has helped us with this cat's diabetic regulation, so I am reluctant to take her off it, yet I do not want to overload "challenged" kidneys. Interestingly, even with the elevation of BUN and dilute urine, the owner feels that Escher's PU/PD is significantly improved from the past (her sugars have been running lower lately--in fact a little too low for my liking). In general, even in a normal cat, is there a point where the BUN is too high when on a higher protein/lower carb diet?
Thanks in advance for your help.
/p | Hypertension? | In what range do the urine s.g.'s consistently sit? |
Hi,
Wasn't sure where to post this, but decided to start here. "Escher" is an approximately 9 y.o. (though I'm starting to suspect older) dsh who became diabetic in the span of one week in 11/11 (normal bloodwork one week, diabetic the next). This was preceded by a brief, ADR episode. Urine specific gravity at the time was 1.038. She was started on glargine and DM diet. She is not a canned food fan, but loves the dry.
She had a nice response to the glargine, though the owner continued to report PU/PD. A month after diagnosis, the owner brought in a contaminated urine sample that appeared to have a USG of 1.012. The BUN, which was 22 at the time of diagnosis, was now 61, which I attributed to the DM diet. Creatinine was 1.6 both times.
We were able to get Escher off insulin about 4 months after diagnosis, but 7 months later, she relapsed. She did continue to eat primarily dry DM during this time. BUN at time of relapse was 81, creatinine 2.5. Two weeks later, her BUN was 59, creatinine 2.0.
Without boring you with the details, Escher has been a little harder to regulate this time, but has generally been doing well. Mom is great, but sometimes a difficult historian as far as how Escher is truly doing. She has consistently reported PU/PD, even when her blood sugars have looked pretty good (I will admit we don't do a lot of curves, but tend to spot check; for the most part Escher has maintained weight throughout this period).
Anyway, her most recent bloodwork showed a BUN of 81, creatinine of 2.2, and a USG of 1.018. My question is, do we expect these changes in BUN and USG from a cat on DM diet? Both numbers were fairly normal at diagnosis, but within a month appear to have changed. If we feel that the decrease in USG represents a loss of concentrating ability due to renal disease, when do we get uncomfortable with the elevation in BUN? Her creatinine has crept up, but is still technically in the normal range at Antech. I feel that the DM has helped us with this cat's diabetic regulation, so I am reluctant to take her off it, yet I do not want to overload "challenged" kidneys. Interestingly, even with the elevation of BUN and dilute urine, the owner feels that Escher's PU/PD is significantly improved from the past (her sugars have been running lower lately--in fact a little too low for my liking). In general, even in a normal cat, is there a point where the BUN is too high when on a higher protein/lower carb diet?
Thanks in advance for your help.
/p | 6.0 mg/dl is the magic number because the phosphorus has to be less than that to be able to use calcitriol....are you familiar with using this? | What site are they using? |
One of our local specialists recommends pregablin instead of gabapentin for possible neuropathic conditions. Is there any advantage?
I can see a disadvantage in cost.
☼ | What are you treating? | Cholesterol level? |
Hi there,
I've a 9yo FN maltese patient, stable diabetic for last 3 months. Recently she has started compulsively licking the floor at home, all over the house, most concentrated on the floor in the kitchen but everywhere. She does it to the point where the owner mops the floor every day and no-one goes without shoes!
I guess my question is, is this likely to be pica issue related to her DM or am I looking more at an OCD behaviour - the dog is starting to show some other cognitive issues.
Thanks for your time.
☼ | What exactly does this mean? | What's the albumin level? |
Hi there,
I've a 9yo FN maltese patient, stable diabetic for last 3 months. Recently she has started compulsively licking the floor at home, all over the house, most concentrated on the floor in the kitchen but everywhere. She does it to the point where the owner mops the floor every day and no-one goes without shoes!
I guess my question is, is this likely to be pica issue related to her DM or am I looking more at an OCD behaviour - the dog is starting to show some other cognitive issues.
Thanks for your time.
☼ | What does a complete neuro exam look like? | Mouth? |
Hi there,
I've a 9yo FN maltese patient, stable diabetic for last 3 months. Recently she has started compulsively licking the floor at home, all over the house, most concentrated on the floor in the kitchen but everywhere. She does it to the point where the owner mops the floor every day and no-one goes without shoes!
I guess my question is, is this likely to be pica issue related to her DM or am I looking more at an OCD behaviour - the dog is starting to show some other cognitive issues.
Thanks for your time.
☼ | Do you have a recent cbc/chem screen? | Do both dogs eat from the same bag/can? |
Hi there,
I've a 9yo FN maltese patient, stable diabetic for last 3 months. Recently she has started compulsively licking the floor at home, all over the house, most concentrated on the floor in the kitchen but everywhere. She does it to the point where the owner mops the floor every day and no-one goes without shoes!
I guess my question is, is this likely to be pica issue related to her DM or am I looking more at an OCD behaviour - the dog is starting to show some other cognitive issues.
Thanks for your time.
☼ | Urine culture is negative since she's been diagnosed? | Very interesting findings! anyone care to comment? |
Bailey is a 15 and a half year old FS kitty who has been diabetic for 6 years and is well controlled. We diagnosed her last week with an intrathoracic mass cranial to the heart. Owners are not interested in pursuing further diagnostics.
She is already being given glucosamine for spinal arthritis. The owners inquired about turmeric - would it be helpful and is there any contraindication with diabetes?
Thanks, | Do you believe the mass is a thymoma? | Do you have a urinalysis on this kitty? |
I have a 10 yr old Ridgeback patient with a retained testicle. He came for his annual and the owner mentioned he has been drinking more( about an ounce per pound). His external testicle is small and mushy and there is a firm 8-9cm mass anterior to his bladder that I suspect is the retained testicle.
He is developing some alopecia with pigmented skin in the perineum, ventral thorax and maybe early lateral abdomen.
His prostate is not enlarged
His lab work was normal except for urine SpGrav of 1.010 and 10-15 WBCs phf in urine with rare bacteria.
I suspect he has a tumor in the retained testicle but can't find in any source that polydipsia would be related. Have you seen any association? I plan xrays and/or ultrasound to further define but wonder how much farther to go looking for source of mild polydipsia before surgery if it is indicated.
Your opinion is much appreciated. Thanks. | How was the urine sample obtained? | Were cortisols measured at a reference lab? |
Hi,
I'm looking for some help regulating a 10 year old 15.61lb poodle. Just trying to fine tune the insulin dose. She is currently receiving 3 units of Humulin or Novolin N insulin, eating W/D well and doing well at home. No more symptoms and the owner are performing the glucose curves at home with the Alphatrak glucometer. The problem is every time I try to take up the dose the owner gets a low reading, sometimes lower than 70, so I then back down to the 3 U again. The low reading may come 2 to 5 hours after the insulin injection and doesn't seem to happen after both the morning and evening injection, not both. The last curve was done Sunday 6-6-13:
5AM 287 and 3 U
7AM 303
9AM 113
11AM 126
1PM 332
3PM 352
5PM 578 and 3U
7PM 416
9PM 284
What do you think?
Thanks Dr. | Hmmm...the first question is whether the owner's glucometer is working well? | When does she get the insulin/food in the am and pm? |
Hi,
I'm looking for some help regulating a 10 year old 15.61lb poodle. Just trying to fine tune the insulin dose. She is currently receiving 3 units of Humulin or Novolin N insulin, eating W/D well and doing well at home. No more symptoms and the owner are performing the glucose curves at home with the Alphatrak glucometer. The problem is every time I try to take up the dose the owner gets a low reading, sometimes lower than 70, so I then back down to the 3 U again. The low reading may come 2 to 5 hours after the insulin injection and doesn't seem to happen after both the morning and evening injection, not both. The last curve was done Sunday 6-6-13:
5AM 287 and 3 U
7AM 303
9AM 113
11AM 126
1PM 332
3PM 352
5PM 578 and 3U
7PM 416
9PM 284
What do you think?
Thanks Dr. | Is this a spayed female? | So if the purina dm isn't tolerated, i'd go with one of the many over-the-counter canned diets that are low enough in carbs (e.g. 'janet and binky's list)---are you familiar with this? |
Hello!
I am getting mixed messages on how to approach this case, and would LOVE to have some concrete input as this is my personal pet. Tigger, an 18 year old, MN, DSH cat presented on 6/4/13 for polyphagia over the past few weeks. He is drinking a bit more water than usual these days, but not excessively. His stool and urination are normal. He vomits on occasion. He has tendencies to vomit once a day for a few days in a row with either a hairball or undigested food, then go for a month or so with no vomiting at all. He has a BCS of 3/5, weighing 8.44 lbs. He is not obese. He has normal activity at home. His diet over the past several years has been various premium diets including Wellness Indoor Formula, Nutro, Blue Buffalo, Natural Instinct, etc. both dry and canned varieties. A CBC revealed a stress leukogram, a Chemistry panel revealed the following: Glucose 258, ALP 111, ALT 243, AST 113, BUN 59, Creatinine 3.0, Lipase 276, Amylase 3106, tBIL 0.5, TP 8.6, Cholesterol 285. T4 is WNL. A u/a has not been done as yet, but should be forthcoming this weekend.
I started him on Glargine 2 units SQ q 12 hours on 6/6/13 and will add the Royal Canin Diabetic diet as well. My question, would you continue Tigger on insulin therapy, or would you consider diet only in this case? My gut feeling, as a newer vet, agrees with insulin therapy, but a colleague of mine is suggesting diet only and NO insulin as insulin could result in hypoglycemia with a Glucose of only 258. My concern with this thought process is that if he is managed with diet only, his glucose could continue to skyrocket and then become uncontrolled. I believe I caught this disease in its early stages, and only want to do what is absolutely best for him. He did have a stressful car ride into the clinic, and was very stressed when blood was drawn, however, w/the elevated liver enzymes and cholesterol, this is classic DM based on my evaluation.
If anyone can offer some treatment advice, I would appreciate it. If I can manage him successfully on diet alone, great; however, the small number of cases that I have seen thus far that have tried to manage kitties on diet alone have failed miserably.
Thank you!
Best, | What was the t4 value? | Fiv/felv negative? |
We don't have a lot of history on this dog but here goes. The owner just got this dog a few months ago. Coco is a FS approximately 9 year old overweight dog. She was diagnosed in 2010 with diabetes. She was on 12 units NPH insulin BID. The other doctor saw the dog 5/3/2013 and presented for low glucose. She was treated and seemed to do fine. Her dose was lowered to 10 units and we rechecked today. Coco's glucose curve at the other clinic on 4/4/13 (before new owner got dog) was: 134 (11 am), 137 (1pm), 99 (3pm), 117 (4 pm), 87 (5 pm).
Today: 217 (before food and 10 units NPH insulin at 8 am)
159 (10 am)
185 (12 pm)
389 (2 pm)
504 (4 pm)
Normally I would increase the dose a little, but I am wondering if we need to switch to another insulin. I am hesistant to go up in dosage since she seemed to have a crisis at 12 units! This doesn't look like my typical overswing. Any thoughts would be appreciated. | Are you absolutely sure she's spayed? | Does the dog dislike these high-fiber diets or does she seem uninterested in most foods? |
We don't have a lot of history on this dog but here goes. The owner just got this dog a few months ago. Coco is a FS approximately 9 year old overweight dog. She was diagnosed in 2010 with diabetes. She was on 12 units NPH insulin BID. The other doctor saw the dog 5/3/2013 and presented for low glucose. She was treated and seemed to do fine. Her dose was lowered to 10 units and we rechecked today. Coco's glucose curve at the other clinic on 4/4/13 (before new owner got dog) was: 134 (11 am), 137 (1pm), 99 (3pm), 117 (4 pm), 87 (5 pm).
Today: 217 (before food and 10 units NPH insulin at 8 am)
159 (10 am)
185 (12 pm)
389 (2 pm)
504 (4 pm)
Normally I would increase the dose a little, but I am wondering if we need to switch to another insulin. I am hesistant to go up in dosage since she seemed to have a crisis at 12 units! This doesn't look like my typical overswing. Any thoughts would be appreciated. | How much does she weigh? | Was it by equilibrium dialysis? |
We don't have a lot of history on this dog but here goes. The owner just got this dog a few months ago. Coco is a FS approximately 9 year old overweight dog. She was diagnosed in 2010 with diabetes. She was on 12 units NPH insulin BID. The other doctor saw the dog 5/3/2013 and presented for low glucose. She was treated and seemed to do fine. Her dose was lowered to 10 units and we rechecked today. Coco's glucose curve at the other clinic on 4/4/13 (before new owner got dog) was: 134 (11 am), 137 (1pm), 99 (3pm), 117 (4 pm), 87 (5 pm).
Today: 217 (before food and 10 units NPH insulin at 8 am)
159 (10 am)
185 (12 pm)
389 (2 pm)
504 (4 pm)
Normally I would increase the dose a little, but I am wondering if we need to switch to another insulin. I am hesistant to go up in dosage since she seemed to have a crisis at 12 units! This doesn't look like my typical overswing. Any thoughts would be appreciated. | What dose of insulin was she on for the curve on 4/4? | Is the dog eating purina om for the fiber or for weight loss? |
We don't have a lot of history on this dog but here goes. The owner just got this dog a few months ago. Coco is a FS approximately 9 year old overweight dog. She was diagnosed in 2010 with diabetes. She was on 12 units NPH insulin BID. The other doctor saw the dog 5/3/2013 and presented for low glucose. She was treated and seemed to do fine. Her dose was lowered to 10 units and we rechecked today. Coco's glucose curve at the other clinic on 4/4/13 (before new owner got dog) was: 134 (11 am), 137 (1pm), 99 (3pm), 117 (4 pm), 87 (5 pm).
Today: 217 (before food and 10 units NPH insulin at 8 am)
159 (10 am)
185 (12 pm)
389 (2 pm)
504 (4 pm)
Normally I would increase the dose a little, but I am wondering if we need to switch to another insulin. I am hesistant to go up in dosage since she seemed to have a crisis at 12 units! This doesn't look like my typical overswing. Any thoughts would be appreciated. | Is she eating normally and settled in her new home? | What is the current insulin dose and what does he weigh? |
Hello again Sherri, and Happy New Year!
Callie had been on 15mg trilostane BID since my last update, daily Pepcid and human cranberry supplementation. She recently finished her 6 weeks of amoxil for the E.coli UTI.
A few days ago her owners called to let me know that she was not herself, they were having to encourage her to eat, and she had some soft stool with blood. I had her come in for an ACTH stim and electrolytes, stopped her trilostane and started 5mg prednisolone BID for the first day, then 2.5mg BID while awaiting results.
Her owners reported an almost instantaneous return to normal with the pred.
Her Na/K ratio was 23, due to hyperkalemia (K 6.8, Na 150). I was tentatively predicting an Addisonian crisis due to trilostane overdose.
However, her ACTH stim results were pre: 182 (15-120), post: 231 (220-550). The ACTH stim was run approx 7-8 hrs post-trilostane. I decided to check for other possible causes of hyperkalemia, so ran a CBC, biochem and repeated her urine culture. Culture results are pending. Her USG in-house was 1.010.
Biochem results (24 hours after starting prednisolone):
Alb 30 (27-39)
ALP 58 (5-160)
ALT 118 (18-121)
Amylase 1143 (337-1469)
AST 27 (16-55)
BUN 34.5 (3.2-11)**
Ca 2.7 (2.2-2.8)
Cl 103 (108-119)**
Chol 8.3 (3.4-8.9)
CK 169 (10-200)
Creat 193 (44-133)**
Glu 6.3 (3.5-6.3)
Lip 552 (138-755)
Phos 2.1 (0.8-2)**
Pot 5 (4-5.4)
Na 145 (142-152)
Tbil 3.4 (0-3.4)
TP 64 (55-75)
Glob 34 (24-40)
A/G ratio 0.9 (0.7-1.5)
Cbil 0.1 (0-1.7)
Hemolysis normal
Icterus normal
Lipemia normal
Na/K ratio 29
Hematology showed mild neutrophilia 14.1x 10^9 (3-11.5), no toxic neutrophils; mild eosinopenia 0x 10^9 (0.1-1.25) and mild lymphopenia 0.8x 10^9 (1-4.8); which I would put down to stress/prednisolone administration.
I would consider the hypochloremia a symptom of Cushing's, but Callie certainly seems to be experiencing chronic renal insufficiency now. My plan will be to check her UPC ratio, switch her to a low protein diet, check her BP, potentially start an ACE inhibitor. I will look into calcitriol/phosphorus binders and SC fluids with clients.
My indecision is regarding the trilostane - I have read the drug book warnings against using trilostane in renal failure, and endocrinology/IM discussions that advise that the benefits of treating her Cushing's outweigh any possible effects. Not sure exactly when to restart and at what dose (back to 15mg BID even though she has low normal post cortisol readings, or perhaps go down to 20mg SID?). Shall I stop the prednisolone altogether now that Na/K ratio is improved? Restart trilostane right away, in one week, in four weeks? (Callie seeming back to her normal self, and trilostane being relatively short-acting from my understanding).
Thanks as always! | Whoops---meant to make sure that you submitted the cortisols to a commercial vet lab, right? | Or can her problems be explained exclusively by acth deficiency? |
Hello! Wrigley is a 8 yo Miniature Poodle with diabetes mellitus and concurrent uroliths (suspect calcium oxalate). His owners have been very compliant with blood glucose curves, but are reluctant to have a cystotomy performed at the moment due to financial concerns (he is not currently having any urinary issues). He has always been a picky eater and had been on RC Venison and Potato for many years, but the owners would alternate periodically with other diets. I diagnosed him with urinary calculi in December 2012, so we transitioned him to RC Urinary SO. He didn't love the food and was picky with it. He was then diagnosed with diabetes in March 2013 and we elected to try RC Diabetic canned (due to the SO index). He has been eating it fairly well over the last two months and we got his diabetes well regulated. In the last few weeks, he now seems disinterested and his owners are having a hard time getting him to eat at the times when he needs insulin. I explained the importance of consistency with food/insulin administration, but his owners are getting frustrated with his lack of interest in food. Clinically, he is doing well - water intake, urination and weight are all stable. I don't want to bounce him back and forth between foods, mostly because of the differences in proteins/fats/carbs, which is what his owners seem to want to do. I did talk about the option of a home-cooked diet, but they are busy professionals and I don't think that they could do it appropriately. Are there other diabetic foods that may be an option for him that the owners can alternate between? I could also add in potassium citrate to help prevent further crystal formation, if needed. Any input/thoughts would be greatly appreciated!
With thanks, | Is there any commercial diet at all that wrigley would eat consistently? | The uccr? |
Giggles is an 11 year old f/s pug. Diagnosed with Addison's in 9-2010 and Diabetes in 12-2010. Well managed with fludrocortisone and Novolin insulin.
Recently came in for weight loss (was obese at 25 lbs, now 16 lbs and a little thin) with her normal excellent appetite. Glucose was high, teeth were horrible, bloodwork showed elevated Alp 1169 (20-150) Alt 202 (1-118). Na:K 31.5. Urine well concentrated with no evidence of a uti.
Routine radiographs showed several pale choleliths, These were also seen with ultrasound. Gall bladder was thickened with surrounding edema.
She's not painful, has not had any vomiting, and her appetite is excellent.
We anesthetized her and extracted most of her teeth. She's on clindamycin and doing well. Plan to bring her back for a glucose curve next week. Did not change the insulin yet - I think those teeth contributed to the hyperglycemia.
My question is the choleliths. Associate tells me not to treat if asymptomatic but I feel like they are a time bomb. Considering ursodiol and culturing bile after dental antibiotics are finished. Of course this is after we get her blood glucose and weight loss under control.
Thanks for any input,
☼ | What is her t bili currently? | Do you have any photos of the claws that you could post here? |
Hi, a Mn 13 year old cat presented for PU/PD. This cat used to belong to the client's father and was an outdoor, normal weight cat. He then became an indoor cat with new owner and went from 10lbs or so to 15lbs within 8 months. He also had a palpable thyroid on one side and a 2/6 heart murmer. He is fat now. CBC/CHEM showed glucose of 512, normal CBC and rest of CHEM WNL's. T4 was 4.6 (N=1.5-4.8). I diagnosed him with Diabetes and started him on Glargine @ 3units BID and had client feed Fancy Feast shrimp,cod,sole. A sugar curve done 2 weeks later showed only little improvement to the numbers. (440-371) over 24 hour monitoring. I increased him to 4 units BID and added M/D dry to his canned diet of Fancy Feast. One week later we did a 12 hr reading after 4 units of glargine. BS was 435. We then increased to 5 units and took a 6 hr reading 3 days later. BG was again 435. Should we try a different insulin? Thanks, ☼ | Can the client learn to curve this cat at home? | Also, could you give the owner link to owners of insulin treated pets? |
Hi all,
I'd like some help with a 12yo MC Bishon dog who presented to our clinic with PUPD. The dog has allergy issues and is treated with 0.5 mg/kg pred on a regular basis. He was also diagnosed with hypothyroidism by a different vet who also treats the dog (the owner moves around so she has vets in 2 cities).
In our clinic, initial blood workup showed elevated ALP (910!!) ALT (134), glucose (346) and total billirubin (1.9). We suspected diabetes induced by iatrogenic cushing's, and we repeated the blood glucose levels in fasting, just to be sure- came back as 451.
Now, clearly this dog's diabetes will not be stabilized until we get him off the prednisone. I've got the following questions:
1) what would be the best (=safest & quickest) way of tapering down the prednisone? The last thing I want to do is add Addison's disease to this dog's endocrinological repertuar.
2) Could the diabetes be reversible once we've gotten the pred out of his system?
3) My colligue put him on insulin, started with 1.75U and raised to 2.5U. The dog's BG is still HI (above the glucometer's range). Will insulin make a difference? Is there a different dose that could work (we are using NPH)?
4) Will diabetic food make a difference with this dog, at least help the glucose levels a little until we taper down the pred.?
Thanks in advance,
☼ | I'm concerned that if the bilirubin is truly elevated (was there hemolysis or lipemia in the sample? | Would you be able to post your radiographs? |
Hello,
I have been treating a westie chronic T3-L3 myelopathy and cp deficits lhl, and normal to hyper-reflexive hind limb reflexes, chronic bilateral cruciate rupture, bilateral mpl, and no severe pain on joint palpation. He is a well regulated diabetic. I referred him to a surgeon to discuss options for treatment - he gets acupuncture, he is on rimadyl and he is on chinese herbs. The surgeon discussed a solumedrol injection into the lumbosacral space and C-pet therapy. The surgeon and I are concerned about how the solumedrol will affect his diabetes. I know it is short acting when injected IV. Apparantly, the positive clinical effects last 6 months. Could it adversely affect his diabetes for 6 months?
Thank you,
☼ | It can lead to plems with regulation of diabetes - how long? | Using u40 syringes or a pen? |
Pooh is a 13 year-old DSH FS who presented three days ago for constipation and recent weight loss. She was examined by a colleague at the practice where I now locum. She was found to be about dehydrated, mildly icteric, and constipated. BP by Doppler 145 mm Hg, HR 124 without arrhythmia or murmur, RR 34 bpm, T 37.3 C. Xrays showed copious fecal pellets in colon, a food-filled stomach, and slightly small kidneys. She was given an enema which cleared her colon, a SC fluid bolus, and started on Denamarin awaiting lab results.
Biochemistry of June 8th on blood collected before any fluid therapy or treatments:
hemolysis normal
icterus +++
lipemia normal
glucose 5.4 (4.0 - 8.0)
BUN 11.0 (5.0 - 12.0)
creatinine 110 (71 - 203)
BUN/Creat ratio 25.1
sodium 150 (147 - 156)
potassium 5.0 (3.0 - 5.3)
Na/K ratio 30
chloride 112 (111 - 125)
bicarb 19 (13 - 25)
anion gap (24.0 (12 - 26)
calcium 2.71 (2.00 - 2.90)
phosphorus 1.48 (1.00 - 2.40)
total protein 74 (59 - 85)
albumin 27 (23 =- 33)
globulin 47 (27 - 51)
A/G ratio 0.6 (0.5 - 1.3)
total bilirubin 130 (0 - 7) HIGH
DIRECT BILIRUBIN 84 (0 - 3) HIGH
ALP 370 (0 - 62) HIGH
ALT 881 (28 - 76) HIGH
AST 199 (5 - 55) HIGH
GGT 3 (0 - 6)
CK 90 (64 - 440)
amylase 1631 (463 - 1833)
lipase 54 (10 - 195)
cholesterol 7.77 (2 - 6) HIGH
calc osmolality 305 (285 - 314)
CBC:
WBCs 19.9 (4.2 - 15.6) HIGH
RBCs 7.5 (6 - 10)
Hb 121 (95 - 150)
HCT 39% (29 - 45)
MCV 52.3 (41 - 58)
MC Hb 16 (11 - 17.5)
platelets adequate, clumped
RDW 21.3 (10 - 26)
% reticulocytes 17
retic. count 12.8 (3 - 50)
neutrophils 74% 14.726 (2.5 - 12.5) HIGH
lymphocytes 15% 2.985 (1.5 - 7.0)
monocytes 3% 0.597 (0 - 0.85)
eosinophils 8.0% 1.592 (0 - 1.5) HIGH
basophils 0.0
No blood parasites found on slide
Spec fPL 4.7 (0 - 3.5) Increased, but in gray zone
TT4 66.8 (10 - 60) HIGH probably even higher when corrected for euthyroid sick effect
Negative for both FIV and FLV on ELISA
U/A on cysto sample:
SpGr 1.026
pH 6.5
urobilinogen 3.2 (3.2 - 16)
blood ++
urine bilirubin +++
glucose negative
ketones negative
protein 1+
large amt. of bacteria seen
WBCs 0-3/HPF
moderate amount of bilirubin crystals
urine culture and sensitivity pending.
Once the results were discussed with owners, the cat was admitted for in-hospital IV fluids, ampicillin and metidazole, an injection of hemostam, and started on methimazole PO. She has not vomited and has been drinking a lot on her own and eating an adequate amount of food.
Today I saw her for readmission and the second day of IV fluids/antibiotics. She was markedly pale and icteric, markedly prolonged skin tent, normal heart and lung sounds, only 30 grams weight gain in 24 hours, abdomen soft and non-painful with no palpable abnormalities except for possibly thickened colon. The concerning finding was a marked drop in PCV from 43% yesterday morning to 31% this morning, with stable total protein (9.1 yesterday vs. 9.0 today). I started her on a conservative rate of IV fluids at 3ml/kg/hr and increased to 4.5ml/kg/hr after two hours, having decided that she can handle some more hemodilution in the face of overwhelming icterus and a UTI which could be a pyelonephritis.
So my main concern at this point are devising adequate fluid therapy rate while being mindful of increasing anemia and now evidence of hemolysis. There was evidence of marked gross hemolysis in the hematocrit tube this morning (and no hemolysis noted when blood was first collected), and the difference in PCV between yesterday and today seems alarming given that the cat has gained hardly any weight (only 30 grams, which may be simple scale error). Since no blood parasites were seen, I am at a bit of a loss at to the cause of the gross hemolysis. I cannot rule out leukemia lurking in the bone marrow and not picked up on ELISA of peripheral blood. She has an inflammatory/infectious process (UTI and hepatopathy), but is that enough to cause immune-mediated hemolysis? Could it be a reaction to any of the medications? Speaking of medications, I would have used ampicillin in combination with baytril but will not change her protocol until urine C+S results are in. I'm also considering adding a series of cobalamin injections. The owner has declined abdominal U/S but may agree to a repeat biochemistry. Any suggestions as to the cause(s) of illness and treatment for the cat would be greatly appreciated. | How was heart rate on most recent recheck? | But what's the point of a few days of symptomatic treatment with a drug that most of us are only starting to use in a few, select cases? |
Pooh is a 13 year-old DSH FS who presented three days ago for constipation and recent weight loss. She was examined by a colleague at the practice where I now locum. She was found to be about dehydrated, mildly icteric, and constipated. BP by Doppler 145 mm Hg, HR 124 without arrhythmia or murmur, RR 34 bpm, T 37.3 C. Xrays showed copious fecal pellets in colon, a food-filled stomach, and slightly small kidneys. She was given an enema which cleared her colon, a SC fluid bolus, and started on Denamarin awaiting lab results.
Biochemistry of June 8th on blood collected before any fluid therapy or treatments:
hemolysis normal
icterus +++
lipemia normal
glucose 5.4 (4.0 - 8.0)
BUN 11.0 (5.0 - 12.0)
creatinine 110 (71 - 203)
BUN/Creat ratio 25.1
sodium 150 (147 - 156)
potassium 5.0 (3.0 - 5.3)
Na/K ratio 30
chloride 112 (111 - 125)
bicarb 19 (13 - 25)
anion gap (24.0 (12 - 26)
calcium 2.71 (2.00 - 2.90)
phosphorus 1.48 (1.00 - 2.40)
total protein 74 (59 - 85)
albumin 27 (23 =- 33)
globulin 47 (27 - 51)
A/G ratio 0.6 (0.5 - 1.3)
total bilirubin 130 (0 - 7) HIGH
DIRECT BILIRUBIN 84 (0 - 3) HIGH
ALP 370 (0 - 62) HIGH
ALT 881 (28 - 76) HIGH
AST 199 (5 - 55) HIGH
GGT 3 (0 - 6)
CK 90 (64 - 440)
amylase 1631 (463 - 1833)
lipase 54 (10 - 195)
cholesterol 7.77 (2 - 6) HIGH
calc osmolality 305 (285 - 314)
CBC:
WBCs 19.9 (4.2 - 15.6) HIGH
RBCs 7.5 (6 - 10)
Hb 121 (95 - 150)
HCT 39% (29 - 45)
MCV 52.3 (41 - 58)
MC Hb 16 (11 - 17.5)
platelets adequate, clumped
RDW 21.3 (10 - 26)
% reticulocytes 17
retic. count 12.8 (3 - 50)
neutrophils 74% 14.726 (2.5 - 12.5) HIGH
lymphocytes 15% 2.985 (1.5 - 7.0)
monocytes 3% 0.597 (0 - 0.85)
eosinophils 8.0% 1.592 (0 - 1.5) HIGH
basophils 0.0
No blood parasites found on slide
Spec fPL 4.7 (0 - 3.5) Increased, but in gray zone
TT4 66.8 (10 - 60) HIGH probably even higher when corrected for euthyroid sick effect
Negative for both FIV and FLV on ELISA
U/A on cysto sample:
SpGr 1.026
pH 6.5
urobilinogen 3.2 (3.2 - 16)
blood ++
urine bilirubin +++
glucose negative
ketones negative
protein 1+
large amt. of bacteria seen
WBCs 0-3/HPF
moderate amount of bilirubin crystals
urine culture and sensitivity pending.
Once the results were discussed with owners, the cat was admitted for in-hospital IV fluids, ampicillin and metidazole, an injection of hemostam, and started on methimazole PO. She has not vomited and has been drinking a lot on her own and eating an adequate amount of food.
Today I saw her for readmission and the second day of IV fluids/antibiotics. She was markedly pale and icteric, markedly prolonged skin tent, normal heart and lung sounds, only 30 grams weight gain in 24 hours, abdomen soft and non-painful with no palpable abnormalities except for possibly thickened colon. The concerning finding was a marked drop in PCV from 43% yesterday morning to 31% this morning, with stable total protein (9.1 yesterday vs. 9.0 today). I started her on a conservative rate of IV fluids at 3ml/kg/hr and increased to 4.5ml/kg/hr after two hours, having decided that she can handle some more hemodilution in the face of overwhelming icterus and a UTI which could be a pyelonephritis.
So my main concern at this point are devising adequate fluid therapy rate while being mindful of increasing anemia and now evidence of hemolysis. There was evidence of marked gross hemolysis in the hematocrit tube this morning (and no hemolysis noted when blood was first collected), and the difference in PCV between yesterday and today seems alarming given that the cat has gained hardly any weight (only 30 grams, which may be simple scale error). Since no blood parasites were seen, I am at a bit of a loss at to the cause of the gross hemolysis. I cannot rule out leukemia lurking in the bone marrow and not picked up on ELISA of peripheral blood. She has an inflammatory/infectious process (UTI and hepatopathy), but is that enough to cause immune-mediated hemolysis? Could it be a reaction to any of the medications? Speaking of medications, I would have used ampicillin in combination with baytril but will not change her protocol until urine C+S results are in. I'm also considering adding a series of cobalamin injections. The owner has declined abdominal U/S but may agree to a repeat biochemistry. Any suggestions as to the cause(s) of illness and treatment for the cat would be greatly appreciated. | Is bp still normal? | The owner is only feeding at mealtimes, when the insulin is given, using a measuring cup and the amount is reasonable for a dog this size (sometimes when the weight is falling off of them they panic and start really over-feeding the dog---which means we have to chase after them with an ever-increasing amount of insulin) what should the dog weigh? |