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Hi all,
I have a question regarding a 13 yr old cat that is on methimazole and came in "not doing well". The exam was pretty normal with the exception of an unkempt coat and foot pads that at last visit were swollen and peeling and now are very soft (saggy) with large cracks, peeling skin and redness. We ran a tapazole panel and BUN and Creat were normal, ALT was low, T4 was 1.8 ug/dL (0.6-3.6). The RBC's were normal at 7.63 but HCT was 23.4%, MCV and MCH were low. I tested iron and got 25 ug/dL (53-145 ug/dL), TIBC 273 ug/dL (226-432ug/dL), and Saturation of 8% (15-49%). I'm thinking this looks like a iron deficiency anemia. I saw Dr. Gaspar's posts regarding compounding ferrus sulfate and giving at 10mg/kg sid. Is there a chance that this will make the cat feel better clinically and how do I monitor this. Do I recheck iron levels and when?
thanks,
Dr. | Hyporexia/anorexia, vomiting, weight loss, etc.? | What diet is this kitty eating? |
Good evening,
I have an approximately 10yo MN diabetic that I am having difficulty regulating (we have done U/As which are WNL). At 4U his curve was as follows:
6:30am fed and 4U lantus
8:30am 329
10:30am 287
12:30pm 284
2:45 pm 286
4:50pm 309
I increased to 4 and 1/2 units and his curve was:
6:40am fed and 4 and 1/2 units insulin
8:20am 282
10am 159
noon 67
1pm 69
2pm 113
4pm 245
I have dropped him back to 4u BID.
In speaking with the owner I learned that during the week she feeds and give insulin at about 6am and 6pm. HOWEVER, weekends are different depending on her work schedule. She either gives it at 6am, 6pm OR on days she works from 3pm to 9pm, she will give him 1/2 his dinner at 3pm with 1/2 insulin dose and do this again a little after 9pm (this is what she did last night for example and may have altered the curve today). As this is not ideal, I am considering having her just feed him and give him his insulin late (9am and 9pm) on the weekends, but what will this do when she has to give it at 9pm on Sunday night and then at 6am monday morning? Same thing with Friday night (6pm) and Saturday morning (9am). Thoughts? Though she has requested not to work 3pm to 9pm, it hasn't been granted. She is financially concerned as well and thus cannot have someone come in to take care of the cat on those days.
Any input would be greatly appreciated. I'm just trying to do the best I can within the means that I have.
Thank you, | How much of what diet is this guy eating and what is his bcs? | What diet is this kitty eating? |
How would you interpret the blood glucose curve for a 9 yr old german shepherd 74.4 lbs.
He was diagnosed with diabetes 8 months ago. His last glucose curve was 12/12 at 22 units NPH BID - nadir 150. I decided to keep him at 22 units and recheck in 4 months. He is doing well at home - gained weight since last PE 4 months. He was previously diagnosed hypothyroid and is getting levothyroxine daily. UA done today - nsf except cocci (not sterile sample).
Pre-insulin - 9 AM 256
NPH 22 units at 9:10 and given w/d
11 AM 207
1 PM 214
3 PM 206
5 PM 229
7 PM 308
I would feel more comfortable if his nadir was lower. Would you keep him at 22 units BID?
Thanks, | Does dog have cataracts yet? | Have you passed a urinary catheter? |
I have a 6 year old FS Ragdoll with persistent hypercalcemia. First diagnosed in 10/2010 on routine labwork. Never been clinical for anything, no PU/PD, no urinary issues. I have spent the last 2.5 years tweaking her doses of prednisolone, fosamax, and diets. Currently on fosamax 10mg 1 tablet once a week, prednisolone 5mg 1 tablet once a day, current diet of Hills W/D dry and Innova canned. Owner can't afford Ionized Ca every visit so we do that once a year. Her last values of iCa was 1.59 (1.16-1.34), Ca 11.8 (8.2-10.8) from May 2012. Her serum calcium levels have been 13.5 (4/14/13)- fasted sample, 13.9 (1/13), 11.8 (10/12), and 12.4 (7/12). Her Cbc, Chem, UA have been unremarkable except serum Ca.
So my question is more tweaking of medications? How high can I go? I was going to increase pred to BID first. Any other options to try?
Any alternative medicine options? I have never treated a hypercalcemic cat with herbals? Anything out there to help potentially? | Could a higher dose be given? | So this sounds like he's subclinical for his heart disease, correct? |
I have a 6 year old FS Ragdoll with persistent hypercalcemia. First diagnosed in 10/2010 on routine labwork. Never been clinical for anything, no PU/PD, no urinary issues. I have spent the last 2.5 years tweaking her doses of prednisolone, fosamax, and diets. Currently on fosamax 10mg 1 tablet once a week, prednisolone 5mg 1 tablet once a day, current diet of Hills W/D dry and Innova canned. Owner can't afford Ionized Ca every visit so we do that once a year. Her last values of iCa was 1.59 (1.16-1.34), Ca 11.8 (8.2-10.8) from May 2012. Her serum calcium levels have been 13.5 (4/14/13)- fasted sample, 13.9 (1/13), 11.8 (10/12), and 12.4 (7/12). Her Cbc, Chem, UA have been unremarkable except serum Ca.
So my question is more tweaking of medications? How high can I go? I was going to increase pred to BID first. Any other options to try?
Any alternative medicine options? I have never treated a hypercalcemic cat with herbals? Anything out there to help potentially? | Could you combine it with pamidronate? | I guess in this case we need to ask ourselves as well, why did the cat end up with di at this late age? |
I have a 6 year old FS Ragdoll with persistent hypercalcemia. First diagnosed in 10/2010 on routine labwork. Never been clinical for anything, no PU/PD, no urinary issues. I have spent the last 2.5 years tweaking her doses of prednisolone, fosamax, and diets. Currently on fosamax 10mg 1 tablet once a week, prednisolone 5mg 1 tablet once a day, current diet of Hills W/D dry and Innova canned. Owner can't afford Ionized Ca every visit so we do that once a year. Her last values of iCa was 1.59 (1.16-1.34), Ca 11.8 (8.2-10.8) from May 2012. Her serum calcium levels have been 13.5 (4/14/13)- fasted sample, 13.9 (1/13), 11.8 (10/12), and 12.4 (7/12). Her Cbc, Chem, UA have been unremarkable except serum Ca.
So my question is more tweaking of medications? How high can I go? I was going to increase pred to BID first. Any other options to try?
Any alternative medicine options? I have never treated a hypercalcemic cat with herbals? Anything out there to help potentially? | Could a higher dose be given...not sure? | Does she have normal vulvar conformation? |
I have a grossly obese 10 yr old, 18 lb (8.18 kg), FS DSH cat named Annie Potts that I am having a hard time with interpretation of a glucose curve (probably due to my lack of experience with it). She also has megacolon (treated with MIralax) and Abd US indicated mild active pancreatitis. She reverted once before on Lantus, but relapsed and is once again a diabetic. Onwer is doing at home glucose curves. I was trying to follow Dr. Rand protocol how to adjust Lantus.
I started her on 2 U SQ q 12 Lantus.
Glucose curve #1: Pre-insulin BG 385, 4 hour post 349. WE increased the dose to 3 U q 12.
Glucose curve #2 : 7 days later:
Blood Glucoses
9:30 am 416 (fasting all night)
9:45 am gave 3 U SQ
1:45 pm 234
5:50 pm 101
7:30 pm food given
7:45 3 U insulin given
10:10 pm 236
I really didnt know how to interpret that so I had her redo one with more values right around the time of insulin adm
Glucose curve #3:
7:45 am 337 (fasting all night)
8:05 am 3 U SQ insulin administered
10:05 am 375
12:05 pm 343
2:05 pm 312
4:05 pm 310
6:05 pm 278
7:30 fed
7:55 pm 249
7:58 pm 3 U SQ insulin administered
10:05 pm 271
I dont know why these are so different. I know this is a long acting insulin, when should the trough be? This cat is alone most of the day so I am afraid not adjusting the dose properly. It is also hard for the owner to monitor PU/PD and due uirine glucose strips as she has a number of cats.
Any help on how to interpret, understand this insulin would be helpful.
Thanks! | What food is annie eating and how many kcals is she eating per day? | Diarrhea or constipation? |
I have a grossly obese 10 yr old, 18 lb (8.18 kg), FS DSH cat named Annie Potts that I am having a hard time with interpretation of a glucose curve (probably due to my lack of experience with it). She also has megacolon (treated with MIralax) and Abd US indicated mild active pancreatitis. She reverted once before on Lantus, but relapsed and is once again a diabetic. Onwer is doing at home glucose curves. I was trying to follow Dr. Rand protocol how to adjust Lantus.
I started her on 2 U SQ q 12 Lantus.
Glucose curve #1: Pre-insulin BG 385, 4 hour post 349. WE increased the dose to 3 U q 12.
Glucose curve #2 : 7 days later:
Blood Glucoses
9:30 am 416 (fasting all night)
9:45 am gave 3 U SQ
1:45 pm 234
5:50 pm 101
7:30 pm food given
7:45 3 U insulin given
10:10 pm 236
I really didnt know how to interpret that so I had her redo one with more values right around the time of insulin adm
Glucose curve #3:
7:45 am 337 (fasting all night)
8:05 am 3 U SQ insulin administered
10:05 am 375
12:05 pm 343
2:05 pm 312
4:05 pm 310
6:05 pm 278
7:30 fed
7:55 pm 249
7:58 pm 3 U SQ insulin administered
10:05 pm 271
I dont know why these are so different. I know this is a long acting insulin, when should the trough be? This cat is alone most of the day so I am afraid not adjusting the dose properly. It is also hard for the owner to monitor PU/PD and due uirine glucose strips as she has a number of cats.
Any help on how to interpret, understand this insulin would be helpful.
Thanks! | Does she have any gi signs? | But from a cv standpoint, just to be sure, was his left atrium severely enlarged on that echo? |
I have a 12 year old, M/N, DSH. He is currently on Prozinc 4 units BID.
On 3/19/13, we did a blood glucose curve and results as followed:
9 am - 366
11 am - 344
1 pm - 346
3 pm - 135
5 pm - 214
I did not increase the insulin due to the 3 pm blood glucose. We ran a fructosamine test and the results were 443 umol/L (191-349).
This rates as fair and borderline poor. The owner can't give me much information on how the pet is doing. They know he eats well but unsure of PU/PD. Recent UA clean and culture no growth.
What are your thoughts on this case? Should I increase the insulin?
Thanks! | Which one is he on? | Maybe a small piece of the reduced fat cheese products? |
I have a 12 year old, M/N, DSH. He is currently on Prozinc 4 units BID.
On 3/19/13, we did a blood glucose curve and results as followed:
9 am - 366
11 am - 344
1 pm - 346
3 pm - 135
5 pm - 214
I did not increase the insulin due to the 3 pm blood glucose. We ran a fructosamine test and the results were 443 umol/L (191-349).
This rates as fair and borderline poor. The owner can't give me much information on how the pet is doing. They know he eats well but unsure of PU/PD. Recent UA clean and culture no growth.
What are your thoughts on this case? Should I increase the insulin?
Thanks! | Is he overweight? | Are you sure the renal function is currently normal? |
Vinnie is a 6 yo MC indoor DSH that presented with ~3# weight loss and some vomiting on Jan.15, 2013. At that time he had a pyoderma (likely FAD) and was treated with a cefovacin injection and labs were submitted to look for metabolic and endocrine causes of weight loss.
Wt history:
4/25/13 - 11 Lbs
2/26/13 - 9.9 Lbs
1/29/13 - 9.42 Lbs
1/22/13 - 9.34 Lbs
1/15/13 - 9.38 Lbs
9/4/12 - 12.5 Lbs
2/13/12 - 12.18 Lbs
Superchem
Total Protein 7.6 5.2-8.8 g/dL
Albumin 3.9 2.5-3.9 g/dL
Globulin 3.7 2.3-5.3 g/dL
A/G Ratio 1.1 0.35-1.5 Ratio
AST (SGOT) 62 10-100 U/L
ALT (SGPT) 91 10-100 U/L
Alk Phosphatase 38 6-102 U/L
GGTP 5 1-10 U/L
Total Bilirubin 0.2 0.1-0.4 mg/dL
Urea Nitrogen 21 14-36 mg/dL
Creatinine 0.8 0.6-2.4 mg/dL
BUN/Creatinine Ratio 26 4-33 Ratio
Phosphorus 4.2 2.4-8.2 mg/dL
Glucose 458 64-170 mg/dL HIGH
The Glucose concentration in this cat is >170 mg/dl. A fructosamine level may be helpful in characterizing the nature of this hyperglycemia and differentiating stress hyperglycemia from early or sub-clinical diabetes mellitus, particularly in obese and/or male cats and/or when hyperglycemia is persistent. Please use test code 85881 for this additional testing.
Calcium 10.1 8.2-10.8 mg/dL
Magnesium 1.6 1.5-2.5 mEq/L
Sodium 148 145-158 mEq/L
Potassium 4.7 3.4-5.6 mEq/L
Na/K Ratio 31
Chloride 108 104-128 mEq/L
Cholesterol 240 75-220 mg/dL HIGH
Triglycerides 53 25-160 mg/dL
Amylase 471 100-1200 U/L
Lipase 58 0-205 U/L
CPK 204 56-529 U/L
Comment
Hemolysis 1+ No significant interference.
CBC
WBC 15.5 3.5-16.0 103/mL
RBC 7.72 5.92-9.93 106/mL
Hemoglobin 11.6 9.3-15.9 g/dL
Hematocrit 32.4 29-48 %
MCV 42 37-61 fL
MCH 15.0 11-21 pg
MCHC 35.8 30-38 g/dL
Platelet Count 316 200-500 103/mL
Platelet EST Adequate Adequate
Differential Absolute %
Neutrophils 11005 71 2500-8500 /uL HIGH
Bands 0 0 0-150 /uL
Lymphocytes 2635 17 1200-8000 /uL
Monocytes 155 1 0-600 /uL
Eosinophils 1705 11 0-1000 /uL HIGH
Basophils 0 0 0-150 /uL
FeLV Antigen (ELISA)
FeLV Antigen (ELISA) Negative
FIV Antibody
FIV Antibody Negative
If recent infection cannot be excluded, retesting >60 days after last exposure is recommended.
Urinalysis
Collection Method
Cystocentesis
Color Yellow
Appearance Clear *Clear
Specific Gravity 1.051 1.015-1.060
pH 5.5 5.5-7.0
Protein Negative Neg
Glucose 3+ Neg HIGH
Result verified.
Ketone Negative Neg
Bilirubin Negative Neg
Blood Negative Neg
WBC 0-1 0-3 HPF
RBC None 0-3 HPF
Casts None Seen LPF
Crystals None Seen HPF
Bacteria None Seen None HPF
Epithelial Cells None Seen HPF
Total T4
Collection Method
T4 1.3 0.8-4.0 ug/dL
Ova and Parasites With Centrifugation
Ova & Parasite None Seen
The following day (1/16/13), I prescribed Glargine insuliin 2 u q12h and Evo 95% poultry canned diet. Here were the instructions given to Mrs:
Newly Diagnosed Feline Diabetics – Monitoring with Glargine Insulin
Materials Required to Home Monitor your cat’s blood glucose:
1. Glucometer (Alpha TRAK is calibrated for canine and feline blood) - Starter kit is ~$200
2. Test Strips (comes with kit)
3. Lancets or needle (comes with the kit)
4. Gauze or cotton ball
5. +/-Warm water and cloth
6. Small flashlight to identify marginal ear vein
7. Treats to reward you kitty after blood sampling
Good websites:
1. http://partnersah.vet.cornell.edu/pet-owners/diabetic-cat
2. http://www.alphatrakmeter.com/index.html
3. http://www.alphatrakmeter.com/alphatrak2-species-specific.html
4. http://www.youtube.com/watch?v=XeZgKLfIJn4
Steps to quickly regulate your newly diagnosed diabetic cat with glargine (Lantus) insulin:
1. Your cat must be fed a diabetic appropriate diet: Royal Canin Diabetic (dry or canned), Purina DM (dry and canned), Evo 95% Beef or Poultry and a host of others.
2. Get baseline blood glucose (BG; normal range 80-120 mg/dL). Get value in the morning BEFORE offering your cat a diabetic appropriate diet.
3. Offer food and if you cat eats, give insulin injection (per your vet’s instructions). Most cats will begin with 1 or 2 units per injection.
4. Check BG every 2 hours for a total of 12 hours (6-7 readings). This is called a BG curve.
5. Glargine insulin to be given every 12 hours.
6. Increase the injection amount by ~ ½ unit per dose UNTIL pre-insulin injection BG is 250 mg/dL.
7. Then, cut dose by ½ a unit and maintain that amount every 12 hours.
8. Repeat BG curve (every 2 hours) in 3-5 days AFTER maintenance dose is determined.
Example:
Time BG (mg/dl) Insulin in units Notes
7 AM 450 2 u Check BG every 2 hours; ate well
7 PM 382 2.5 u Ate well
7 AM 304 3 u Ate well
7 PM 237 2.5 u Ate well
7 AM 2.5 u Ate well
7 PM 2.5 u Ate well
**Repeat 12 hour BG curve on Day 5-7.
Please email results to me every few days:
or fax 239-676-5691.
***The most important thing to remember when using this radical dosing scheme is CAREFUL and ACCURATE MONITORING. The potential for overdosing (causing low blood glucose levels; 70 mg/dL) is high, but the benefit of immediately reversing glucose toxicity and achieving remission far outweighs the risk.***
Once your cat has achieved a stable diabetic, it is recommended to perform a home BG curve monthly.
Good Luck! You can do it!
1/22/13 - 9.34 Lbs
O purchased alpha trak 2 monitor. We calibrated the monitor in office and Vin's reading at 9;30 AM was 505. Administered 2 u SC and he ate 1/3 can Evo 95% in office. Mrs. returned home and at 11:30 his reading was 326.
Mrs was getting used to getting level, but wasn't always successful. She submitted the following readings on 1/28/13:
7:30 AM 2 u glargine
368 at 11:50 AM
456 at 4:00 PM
Mrs. was getting frustrated w/ reading, so I had Vin come in for a day BG curve on 1/29/13
1/29/13:- 9.42 Lbs
Fed and gave 2 u at 8 AM
9:15 AM 393 mg/dl (alpha trak)
11:15 AM 375 mg/dl (alpha trak)
1:15 PM 334 mg/dl (alpha trak)
3:15 PM 398 mg/dl (alpha trak)
4:15 PM 343mg/dl (alpha trak)
Plan: increase to 3 u
2/12/13:
Applied FL tritak
T: 101.2, P: 210, R:30
Fed and gave 3 u glargine at 7:10 AM
BG at 9 AM - 279 mg/dl. o to continue home BG curve q2h until 7 PM
11 am: 165 food and drink given
1 pm: 182
3:05 297
4:40 361
7pm 401
Plan: Keep at 3 u BID. Feed and insulin q12h. Evo 95%. Rec o do home BG curve in 2 weeks and submit results to office for interpretation. Will mail test strips to Mrs.
2/13/13 - losing interest in Evo 95%, began Royal Canin's Diabetic dry formula.
2/26/13 - 9.9 Lbs
o still frustrated with home BG curve so did in house
390 mg/dl (alpha trak) @ 9AM
434 mg/dl (alpha trak) @ 11 AM
389 mg/dl (alpha trak) @ 1 PM
373 mg/dl (alpha trak) @ 3 PM
372 mg/dl (alpha trak) @ 4:30 PM
* dogs barking during hospitalization. Confirmed with owner that she is confident that she got his 3 u of glargine in this AM.
Has left insulin out of refrig over night 2 x in past week.
Keep at 3 u and o to do home BG curve in ~ 2 weeks. Gained more weight and less pd/pu
Home BG
readings
3/3/13; Sunday
12:30 454
Increase to 4 u q12h
3/4/13, Monday
12:30 526
4:30 576
5:00 4 units insulin
7:00 439
9:00pm 413
3/5/13
Tuesday 6:30am 4 units insulin
7:30am 515
8:30am 424
8:30 pm 482
O has taken away all purina food and only giving Evo and RC diabetic
3/6/13
6 am 227, insulin
8 am 77
6:30 pm 571
Decrease to 3.5 u q12h
BG readings: 3/11/13
8:00 am 3.5 units insulin
2:00pm 295
4:00pm 456
8:30pm 536
good appetite likes dry better than evoo drinking fine
Increase to 4 units and recheck BG curve AT HOME in 7-10 days
3/18/13 - Purchased new bottle of glargine
Vinnie had diarrhea this morning. O was out of diabetic food and fed fancy feast. possibly cause of diarrhea
3/18-20/13 HOME BG curve:
Date (s): 3/18/13
Time(s)
AM BG mg/dl Appetite/Notes
9 412
Date (s): 3/19/13
Time(s)
AM BG mg/dl Appetite/Notes
8 423
8:40 4 u
10:40 390
PM
12:30 349
8:30 584 4u
10:30 388
Date (s): 3/20/13
Time(s)
AM BG mg/dl Appetite/Notes
6:30 512 4u
8:10 503
PM
7:45 gave insulin
9:45 473
3/21/13
6:15 4.5 units insulin
8:30 409
seems to be eating better, giving botho evoo and RC
PLAN:
Increase to 4.5 u q12h
Home BG
3/22/13:
6:00am 4.5 units
8:00am 359
BG readings: with 4.5 units
3/23 10:15 pm 597
3/24 7:30 am Insulin; 9:30 am 411
3/25 3:30 pm Vomited food; 4:50 pm 363
Diet: Wet and Dry; o. to transition pt. to Dry only.
3/25/13
5:00pm 363, 4.5 units
7:30pm 341
3/26/13
7:15am 4.5 units
9:15 513
Urinated outside of the litter box today
9:20pm 378
3/27/13
6:15am 4.5 units
8:15am 354
6:00pm 4.5 units
7:45 554
good appetite
3/28/13:
Began RC's diabetic canned in addition to RC's diabetic dry
Mrs. Lost her job. Vinnie is urinating out of litter box. Disc possible UTI. o cannot afford UC&S.
Rx amoxi100 ml po q12h - liquid as it is free from local supermarket pharmacy
Unable to administer
4/7/13: disc concerns of glargine dose getting too high. I want to drop back to 2 u and start over, but lets see what his humbers are next week. Doing well, per mrs., but periods of lethargy at home. I wonder if he is dropping too low.
4/15/13:
came in for cefovacin injection for possible UTI - off label tx. Good news is o found another job :) but is behind financially, rent, etc.. Vinnie gained another 1.1 lbs (upto 11 lbs)
Date (s): 4/15/13
Time(s)
AM BG mg/dl Appetite/Notes
9:00 4.5 u glargine
10:30 176 in office
**concern of possibly catching BG on its way up. Plan is for mrs. to return home, check BG q2h until next meal/dose and then check q1h until bedtime
PM
12:30 126
eating well
2:30 365
4:30 480
6:30 501
7:00 4.5 units of insulin
8:00 514
9:00 543
10:00 525
So, time for questions.
With the latest curve, I was happy to see the 12:30 reading, but then after the 7 PM dose, why is this occurring? I cannot blame lack of response to insulin b/c her responded in the morning. I suppose if the owner did not inject the insulin properly at 7 PM, that could be the cause, but after 3 months, I am sure she has a handle on it.
Could this just be the wrong insulin for Vin?
Thanks for reviewing. I know I gave you lots of data. | Does vinnie prefer dry food? | How much does he weigh? |
Vinnie is a 6 yo MC indoor DSH that presented with ~3# weight loss and some vomiting on Jan.15, 2013. At that time he had a pyoderma (likely FAD) and was treated with a cefovacin injection and labs were submitted to look for metabolic and endocrine causes of weight loss.
Wt history:
4/25/13 - 11 Lbs
2/26/13 - 9.9 Lbs
1/29/13 - 9.42 Lbs
1/22/13 - 9.34 Lbs
1/15/13 - 9.38 Lbs
9/4/12 - 12.5 Lbs
2/13/12 - 12.18 Lbs
Superchem
Total Protein 7.6 5.2-8.8 g/dL
Albumin 3.9 2.5-3.9 g/dL
Globulin 3.7 2.3-5.3 g/dL
A/G Ratio 1.1 0.35-1.5 Ratio
AST (SGOT) 62 10-100 U/L
ALT (SGPT) 91 10-100 U/L
Alk Phosphatase 38 6-102 U/L
GGTP 5 1-10 U/L
Total Bilirubin 0.2 0.1-0.4 mg/dL
Urea Nitrogen 21 14-36 mg/dL
Creatinine 0.8 0.6-2.4 mg/dL
BUN/Creatinine Ratio 26 4-33 Ratio
Phosphorus 4.2 2.4-8.2 mg/dL
Glucose 458 64-170 mg/dL HIGH
The Glucose concentration in this cat is >170 mg/dl. A fructosamine level may be helpful in characterizing the nature of this hyperglycemia and differentiating stress hyperglycemia from early or sub-clinical diabetes mellitus, particularly in obese and/or male cats and/or when hyperglycemia is persistent. Please use test code 85881 for this additional testing.
Calcium 10.1 8.2-10.8 mg/dL
Magnesium 1.6 1.5-2.5 mEq/L
Sodium 148 145-158 mEq/L
Potassium 4.7 3.4-5.6 mEq/L
Na/K Ratio 31
Chloride 108 104-128 mEq/L
Cholesterol 240 75-220 mg/dL HIGH
Triglycerides 53 25-160 mg/dL
Amylase 471 100-1200 U/L
Lipase 58 0-205 U/L
CPK 204 56-529 U/L
Comment
Hemolysis 1+ No significant interference.
CBC
WBC 15.5 3.5-16.0 103/mL
RBC 7.72 5.92-9.93 106/mL
Hemoglobin 11.6 9.3-15.9 g/dL
Hematocrit 32.4 29-48 %
MCV 42 37-61 fL
MCH 15.0 11-21 pg
MCHC 35.8 30-38 g/dL
Platelet Count 316 200-500 103/mL
Platelet EST Adequate Adequate
Differential Absolute %
Neutrophils 11005 71 2500-8500 /uL HIGH
Bands 0 0 0-150 /uL
Lymphocytes 2635 17 1200-8000 /uL
Monocytes 155 1 0-600 /uL
Eosinophils 1705 11 0-1000 /uL HIGH
Basophils 0 0 0-150 /uL
FeLV Antigen (ELISA)
FeLV Antigen (ELISA) Negative
FIV Antibody
FIV Antibody Negative
If recent infection cannot be excluded, retesting >60 days after last exposure is recommended.
Urinalysis
Collection Method
Cystocentesis
Color Yellow
Appearance Clear *Clear
Specific Gravity 1.051 1.015-1.060
pH 5.5 5.5-7.0
Protein Negative Neg
Glucose 3+ Neg HIGH
Result verified.
Ketone Negative Neg
Bilirubin Negative Neg
Blood Negative Neg
WBC 0-1 0-3 HPF
RBC None 0-3 HPF
Casts None Seen LPF
Crystals None Seen HPF
Bacteria None Seen None HPF
Epithelial Cells None Seen HPF
Total T4
Collection Method
T4 1.3 0.8-4.0 ug/dL
Ova and Parasites With Centrifugation
Ova & Parasite None Seen
The following day (1/16/13), I prescribed Glargine insuliin 2 u q12h and Evo 95% poultry canned diet. Here were the instructions given to Mrs:
Newly Diagnosed Feline Diabetics – Monitoring with Glargine Insulin
Materials Required to Home Monitor your cat’s blood glucose:
1. Glucometer (Alpha TRAK is calibrated for canine and feline blood) - Starter kit is ~$200
2. Test Strips (comes with kit)
3. Lancets or needle (comes with the kit)
4. Gauze or cotton ball
5. +/-Warm water and cloth
6. Small flashlight to identify marginal ear vein
7. Treats to reward you kitty after blood sampling
Good websites:
1. http://partnersah.vet.cornell.edu/pet-owners/diabetic-cat
2. http://www.alphatrakmeter.com/index.html
3. http://www.alphatrakmeter.com/alphatrak2-species-specific.html
4. http://www.youtube.com/watch?v=XeZgKLfIJn4
Steps to quickly regulate your newly diagnosed diabetic cat with glargine (Lantus) insulin:
1. Your cat must be fed a diabetic appropriate diet: Royal Canin Diabetic (dry or canned), Purina DM (dry and canned), Evo 95% Beef or Poultry and a host of others.
2. Get baseline blood glucose (BG; normal range 80-120 mg/dL). Get value in the morning BEFORE offering your cat a diabetic appropriate diet.
3. Offer food and if you cat eats, give insulin injection (per your vet’s instructions). Most cats will begin with 1 or 2 units per injection.
4. Check BG every 2 hours for a total of 12 hours (6-7 readings). This is called a BG curve.
5. Glargine insulin to be given every 12 hours.
6. Increase the injection amount by ~ ½ unit per dose UNTIL pre-insulin injection BG is 250 mg/dL.
7. Then, cut dose by ½ a unit and maintain that amount every 12 hours.
8. Repeat BG curve (every 2 hours) in 3-5 days AFTER maintenance dose is determined.
Example:
Time BG (mg/dl) Insulin in units Notes
7 AM 450 2 u Check BG every 2 hours; ate well
7 PM 382 2.5 u Ate well
7 AM 304 3 u Ate well
7 PM 237 2.5 u Ate well
7 AM 2.5 u Ate well
7 PM 2.5 u Ate well
**Repeat 12 hour BG curve on Day 5-7.
Please email results to me every few days:
or fax 239-676-5691.
***The most important thing to remember when using this radical dosing scheme is CAREFUL and ACCURATE MONITORING. The potential for overdosing (causing low blood glucose levels; 70 mg/dL) is high, but the benefit of immediately reversing glucose toxicity and achieving remission far outweighs the risk.***
Once your cat has achieved a stable diabetic, it is recommended to perform a home BG curve monthly.
Good Luck! You can do it!
1/22/13 - 9.34 Lbs
O purchased alpha trak 2 monitor. We calibrated the monitor in office and Vin's reading at 9;30 AM was 505. Administered 2 u SC and he ate 1/3 can Evo 95% in office. Mrs. returned home and at 11:30 his reading was 326.
Mrs was getting used to getting level, but wasn't always successful. She submitted the following readings on 1/28/13:
7:30 AM 2 u glargine
368 at 11:50 AM
456 at 4:00 PM
Mrs. was getting frustrated w/ reading, so I had Vin come in for a day BG curve on 1/29/13
1/29/13:- 9.42 Lbs
Fed and gave 2 u at 8 AM
9:15 AM 393 mg/dl (alpha trak)
11:15 AM 375 mg/dl (alpha trak)
1:15 PM 334 mg/dl (alpha trak)
3:15 PM 398 mg/dl (alpha trak)
4:15 PM 343mg/dl (alpha trak)
Plan: increase to 3 u
2/12/13:
Applied FL tritak
T: 101.2, P: 210, R:30
Fed and gave 3 u glargine at 7:10 AM
BG at 9 AM - 279 mg/dl. o to continue home BG curve q2h until 7 PM
11 am: 165 food and drink given
1 pm: 182
3:05 297
4:40 361
7pm 401
Plan: Keep at 3 u BID. Feed and insulin q12h. Evo 95%. Rec o do home BG curve in 2 weeks and submit results to office for interpretation. Will mail test strips to Mrs.
2/13/13 - losing interest in Evo 95%, began Royal Canin's Diabetic dry formula.
2/26/13 - 9.9 Lbs
o still frustrated with home BG curve so did in house
390 mg/dl (alpha trak) @ 9AM
434 mg/dl (alpha trak) @ 11 AM
389 mg/dl (alpha trak) @ 1 PM
373 mg/dl (alpha trak) @ 3 PM
372 mg/dl (alpha trak) @ 4:30 PM
* dogs barking during hospitalization. Confirmed with owner that she is confident that she got his 3 u of glargine in this AM.
Has left insulin out of refrig over night 2 x in past week.
Keep at 3 u and o to do home BG curve in ~ 2 weeks. Gained more weight and less pd/pu
Home BG
readings
3/3/13; Sunday
12:30 454
Increase to 4 u q12h
3/4/13, Monday
12:30 526
4:30 576
5:00 4 units insulin
7:00 439
9:00pm 413
3/5/13
Tuesday 6:30am 4 units insulin
7:30am 515
8:30am 424
8:30 pm 482
O has taken away all purina food and only giving Evo and RC diabetic
3/6/13
6 am 227, insulin
8 am 77
6:30 pm 571
Decrease to 3.5 u q12h
BG readings: 3/11/13
8:00 am 3.5 units insulin
2:00pm 295
4:00pm 456
8:30pm 536
good appetite likes dry better than evoo drinking fine
Increase to 4 units and recheck BG curve AT HOME in 7-10 days
3/18/13 - Purchased new bottle of glargine
Vinnie had diarrhea this morning. O was out of diabetic food and fed fancy feast. possibly cause of diarrhea
3/18-20/13 HOME BG curve:
Date (s): 3/18/13
Time(s)
AM BG mg/dl Appetite/Notes
9 412
Date (s): 3/19/13
Time(s)
AM BG mg/dl Appetite/Notes
8 423
8:40 4 u
10:40 390
PM
12:30 349
8:30 584 4u
10:30 388
Date (s): 3/20/13
Time(s)
AM BG mg/dl Appetite/Notes
6:30 512 4u
8:10 503
PM
7:45 gave insulin
9:45 473
3/21/13
6:15 4.5 units insulin
8:30 409
seems to be eating better, giving botho evoo and RC
PLAN:
Increase to 4.5 u q12h
Home BG
3/22/13:
6:00am 4.5 units
8:00am 359
BG readings: with 4.5 units
3/23 10:15 pm 597
3/24 7:30 am Insulin; 9:30 am 411
3/25 3:30 pm Vomited food; 4:50 pm 363
Diet: Wet and Dry; o. to transition pt. to Dry only.
3/25/13
5:00pm 363, 4.5 units
7:30pm 341
3/26/13
7:15am 4.5 units
9:15 513
Urinated outside of the litter box today
9:20pm 378
3/27/13
6:15am 4.5 units
8:15am 354
6:00pm 4.5 units
7:45 554
good appetite
3/28/13:
Began RC's diabetic canned in addition to RC's diabetic dry
Mrs. Lost her job. Vinnie is urinating out of litter box. Disc possible UTI. o cannot afford UC&S.
Rx amoxi100 ml po q12h - liquid as it is free from local supermarket pharmacy
Unable to administer
4/7/13: disc concerns of glargine dose getting too high. I want to drop back to 2 u and start over, but lets see what his humbers are next week. Doing well, per mrs., but periods of lethargy at home. I wonder if he is dropping too low.
4/15/13:
came in for cefovacin injection for possible UTI - off label tx. Good news is o found another job :) but is behind financially, rent, etc.. Vinnie gained another 1.1 lbs (upto 11 lbs)
Date (s): 4/15/13
Time(s)
AM BG mg/dl Appetite/Notes
9:00 4.5 u glargine
10:30 176 in office
**concern of possibly catching BG on its way up. Plan is for mrs. to return home, check BG q2h until next meal/dose and then check q1h until bedtime
PM
12:30 126
eating well
2:30 365
4:30 480
6:30 501
7:00 4.5 units of insulin
8:00 514
9:00 543
10:00 525
So, time for questions.
With the latest curve, I was happy to see the 12:30 reading, but then after the 7 PM dose, why is this occurring? I cannot blame lack of response to insulin b/c her responded in the morning. I suppose if the owner did not inject the insulin properly at 7 PM, that could be the cause, but after 3 months, I am sure she has a handle on it.
Could this just be the wrong insulin for Vin?
Thanks for reviewing. I know I gave you lots of data. | Will he eat canned diets eagerly? | Would it eat more if offered? |
Vinnie is a 6 yo MC indoor DSH that presented with ~3# weight loss and some vomiting on Jan.15, 2013. At that time he had a pyoderma (likely FAD) and was treated with a cefovacin injection and labs were submitted to look for metabolic and endocrine causes of weight loss.
Wt history:
4/25/13 - 11 Lbs
2/26/13 - 9.9 Lbs
1/29/13 - 9.42 Lbs
1/22/13 - 9.34 Lbs
1/15/13 - 9.38 Lbs
9/4/12 - 12.5 Lbs
2/13/12 - 12.18 Lbs
Superchem
Total Protein 7.6 5.2-8.8 g/dL
Albumin 3.9 2.5-3.9 g/dL
Globulin 3.7 2.3-5.3 g/dL
A/G Ratio 1.1 0.35-1.5 Ratio
AST (SGOT) 62 10-100 U/L
ALT (SGPT) 91 10-100 U/L
Alk Phosphatase 38 6-102 U/L
GGTP 5 1-10 U/L
Total Bilirubin 0.2 0.1-0.4 mg/dL
Urea Nitrogen 21 14-36 mg/dL
Creatinine 0.8 0.6-2.4 mg/dL
BUN/Creatinine Ratio 26 4-33 Ratio
Phosphorus 4.2 2.4-8.2 mg/dL
Glucose 458 64-170 mg/dL HIGH
The Glucose concentration in this cat is >170 mg/dl. A fructosamine level may be helpful in characterizing the nature of this hyperglycemia and differentiating stress hyperglycemia from early or sub-clinical diabetes mellitus, particularly in obese and/or male cats and/or when hyperglycemia is persistent. Please use test code 85881 for this additional testing.
Calcium 10.1 8.2-10.8 mg/dL
Magnesium 1.6 1.5-2.5 mEq/L
Sodium 148 145-158 mEq/L
Potassium 4.7 3.4-5.6 mEq/L
Na/K Ratio 31
Chloride 108 104-128 mEq/L
Cholesterol 240 75-220 mg/dL HIGH
Triglycerides 53 25-160 mg/dL
Amylase 471 100-1200 U/L
Lipase 58 0-205 U/L
CPK 204 56-529 U/L
Comment
Hemolysis 1+ No significant interference.
CBC
WBC 15.5 3.5-16.0 103/mL
RBC 7.72 5.92-9.93 106/mL
Hemoglobin 11.6 9.3-15.9 g/dL
Hematocrit 32.4 29-48 %
MCV 42 37-61 fL
MCH 15.0 11-21 pg
MCHC 35.8 30-38 g/dL
Platelet Count 316 200-500 103/mL
Platelet EST Adequate Adequate
Differential Absolute %
Neutrophils 11005 71 2500-8500 /uL HIGH
Bands 0 0 0-150 /uL
Lymphocytes 2635 17 1200-8000 /uL
Monocytes 155 1 0-600 /uL
Eosinophils 1705 11 0-1000 /uL HIGH
Basophils 0 0 0-150 /uL
FeLV Antigen (ELISA)
FeLV Antigen (ELISA) Negative
FIV Antibody
FIV Antibody Negative
If recent infection cannot be excluded, retesting >60 days after last exposure is recommended.
Urinalysis
Collection Method
Cystocentesis
Color Yellow
Appearance Clear *Clear
Specific Gravity 1.051 1.015-1.060
pH 5.5 5.5-7.0
Protein Negative Neg
Glucose 3+ Neg HIGH
Result verified.
Ketone Negative Neg
Bilirubin Negative Neg
Blood Negative Neg
WBC 0-1 0-3 HPF
RBC None 0-3 HPF
Casts None Seen LPF
Crystals None Seen HPF
Bacteria None Seen None HPF
Epithelial Cells None Seen HPF
Total T4
Collection Method
T4 1.3 0.8-4.0 ug/dL
Ova and Parasites With Centrifugation
Ova & Parasite None Seen
The following day (1/16/13), I prescribed Glargine insuliin 2 u q12h and Evo 95% poultry canned diet. Here were the instructions given to Mrs:
Newly Diagnosed Feline Diabetics – Monitoring with Glargine Insulin
Materials Required to Home Monitor your cat’s blood glucose:
1. Glucometer (Alpha TRAK is calibrated for canine and feline blood) - Starter kit is ~$200
2. Test Strips (comes with kit)
3. Lancets or needle (comes with the kit)
4. Gauze or cotton ball
5. +/-Warm water and cloth
6. Small flashlight to identify marginal ear vein
7. Treats to reward you kitty after blood sampling
Good websites:
1. http://partnersah.vet.cornell.edu/pet-owners/diabetic-cat
2. http://www.alphatrakmeter.com/index.html
3. http://www.alphatrakmeter.com/alphatrak2-species-specific.html
4. http://www.youtube.com/watch?v=XeZgKLfIJn4
Steps to quickly regulate your newly diagnosed diabetic cat with glargine (Lantus) insulin:
1. Your cat must be fed a diabetic appropriate diet: Royal Canin Diabetic (dry or canned), Purina DM (dry and canned), Evo 95% Beef or Poultry and a host of others.
2. Get baseline blood glucose (BG; normal range 80-120 mg/dL). Get value in the morning BEFORE offering your cat a diabetic appropriate diet.
3. Offer food and if you cat eats, give insulin injection (per your vet’s instructions). Most cats will begin with 1 or 2 units per injection.
4. Check BG every 2 hours for a total of 12 hours (6-7 readings). This is called a BG curve.
5. Glargine insulin to be given every 12 hours.
6. Increase the injection amount by ~ ½ unit per dose UNTIL pre-insulin injection BG is 250 mg/dL.
7. Then, cut dose by ½ a unit and maintain that amount every 12 hours.
8. Repeat BG curve (every 2 hours) in 3-5 days AFTER maintenance dose is determined.
Example:
Time BG (mg/dl) Insulin in units Notes
7 AM 450 2 u Check BG every 2 hours; ate well
7 PM 382 2.5 u Ate well
7 AM 304 3 u Ate well
7 PM 237 2.5 u Ate well
7 AM 2.5 u Ate well
7 PM 2.5 u Ate well
**Repeat 12 hour BG curve on Day 5-7.
Please email results to me every few days:
or fax 239-676-5691.
***The most important thing to remember when using this radical dosing scheme is CAREFUL and ACCURATE MONITORING. The potential for overdosing (causing low blood glucose levels; 70 mg/dL) is high, but the benefit of immediately reversing glucose toxicity and achieving remission far outweighs the risk.***
Once your cat has achieved a stable diabetic, it is recommended to perform a home BG curve monthly.
Good Luck! You can do it!
1/22/13 - 9.34 Lbs
O purchased alpha trak 2 monitor. We calibrated the monitor in office and Vin's reading at 9;30 AM was 505. Administered 2 u SC and he ate 1/3 can Evo 95% in office. Mrs. returned home and at 11:30 his reading was 326.
Mrs was getting used to getting level, but wasn't always successful. She submitted the following readings on 1/28/13:
7:30 AM 2 u glargine
368 at 11:50 AM
456 at 4:00 PM
Mrs. was getting frustrated w/ reading, so I had Vin come in for a day BG curve on 1/29/13
1/29/13:- 9.42 Lbs
Fed and gave 2 u at 8 AM
9:15 AM 393 mg/dl (alpha trak)
11:15 AM 375 mg/dl (alpha trak)
1:15 PM 334 mg/dl (alpha trak)
3:15 PM 398 mg/dl (alpha trak)
4:15 PM 343mg/dl (alpha trak)
Plan: increase to 3 u
2/12/13:
Applied FL tritak
T: 101.2, P: 210, R:30
Fed and gave 3 u glargine at 7:10 AM
BG at 9 AM - 279 mg/dl. o to continue home BG curve q2h until 7 PM
11 am: 165 food and drink given
1 pm: 182
3:05 297
4:40 361
7pm 401
Plan: Keep at 3 u BID. Feed and insulin q12h. Evo 95%. Rec o do home BG curve in 2 weeks and submit results to office for interpretation. Will mail test strips to Mrs.
2/13/13 - losing interest in Evo 95%, began Royal Canin's Diabetic dry formula.
2/26/13 - 9.9 Lbs
o still frustrated with home BG curve so did in house
390 mg/dl (alpha trak) @ 9AM
434 mg/dl (alpha trak) @ 11 AM
389 mg/dl (alpha trak) @ 1 PM
373 mg/dl (alpha trak) @ 3 PM
372 mg/dl (alpha trak) @ 4:30 PM
* dogs barking during hospitalization. Confirmed with owner that she is confident that she got his 3 u of glargine in this AM.
Has left insulin out of refrig over night 2 x in past week.
Keep at 3 u and o to do home BG curve in ~ 2 weeks. Gained more weight and less pd/pu
Home BG
readings
3/3/13; Sunday
12:30 454
Increase to 4 u q12h
3/4/13, Monday
12:30 526
4:30 576
5:00 4 units insulin
7:00 439
9:00pm 413
3/5/13
Tuesday 6:30am 4 units insulin
7:30am 515
8:30am 424
8:30 pm 482
O has taken away all purina food and only giving Evo and RC diabetic
3/6/13
6 am 227, insulin
8 am 77
6:30 pm 571
Decrease to 3.5 u q12h
BG readings: 3/11/13
8:00 am 3.5 units insulin
2:00pm 295
4:00pm 456
8:30pm 536
good appetite likes dry better than evoo drinking fine
Increase to 4 units and recheck BG curve AT HOME in 7-10 days
3/18/13 - Purchased new bottle of glargine
Vinnie had diarrhea this morning. O was out of diabetic food and fed fancy feast. possibly cause of diarrhea
3/18-20/13 HOME BG curve:
Date (s): 3/18/13
Time(s)
AM BG mg/dl Appetite/Notes
9 412
Date (s): 3/19/13
Time(s)
AM BG mg/dl Appetite/Notes
8 423
8:40 4 u
10:40 390
PM
12:30 349
8:30 584 4u
10:30 388
Date (s): 3/20/13
Time(s)
AM BG mg/dl Appetite/Notes
6:30 512 4u
8:10 503
PM
7:45 gave insulin
9:45 473
3/21/13
6:15 4.5 units insulin
8:30 409
seems to be eating better, giving botho evoo and RC
PLAN:
Increase to 4.5 u q12h
Home BG
3/22/13:
6:00am 4.5 units
8:00am 359
BG readings: with 4.5 units
3/23 10:15 pm 597
3/24 7:30 am Insulin; 9:30 am 411
3/25 3:30 pm Vomited food; 4:50 pm 363
Diet: Wet and Dry; o. to transition pt. to Dry only.
3/25/13
5:00pm 363, 4.5 units
7:30pm 341
3/26/13
7:15am 4.5 units
9:15 513
Urinated outside of the litter box today
9:20pm 378
3/27/13
6:15am 4.5 units
8:15am 354
6:00pm 4.5 units
7:45 554
good appetite
3/28/13:
Began RC's diabetic canned in addition to RC's diabetic dry
Mrs. Lost her job. Vinnie is urinating out of litter box. Disc possible UTI. o cannot afford UC&S.
Rx amoxi100 ml po q12h - liquid as it is free from local supermarket pharmacy
Unable to administer
4/7/13: disc concerns of glargine dose getting too high. I want to drop back to 2 u and start over, but lets see what his humbers are next week. Doing well, per mrs., but periods of lethargy at home. I wonder if he is dropping too low.
4/15/13:
came in for cefovacin injection for possible UTI - off label tx. Good news is o found another job :) but is behind financially, rent, etc.. Vinnie gained another 1.1 lbs (upto 11 lbs)
Date (s): 4/15/13
Time(s)
AM BG mg/dl Appetite/Notes
9:00 4.5 u glargine
10:30 176 in office
**concern of possibly catching BG on its way up. Plan is for mrs. to return home, check BG q2h until next meal/dose and then check q1h until bedtime
PM
12:30 126
eating well
2:30 365
4:30 480
6:30 501
7:00 4.5 units of insulin
8:00 514
9:00 543
10:00 525
So, time for questions.
With the latest curve, I was happy to see the 12:30 reading, but then after the 7 PM dose, why is this occurring? I cannot blame lack of response to insulin b/c her responded in the morning. I suppose if the owner did not inject the insulin properly at 7 PM, that could be the cause, but after 3 months, I am sure she has a handle on it.
Could this just be the wrong insulin for Vin?
Thanks for reviewing. I know I gave you lots of data. | Was his bcs elevated at his highest weight? | (e.g. pu/pd? |
Hello,
I have a 13 yo MN DSH who has been diabetic for about 2 years, currently on PZI 1.5 units BID and his last curve and fructosamine show good regulation, currently non-clinical, on MD diet. Over the past 6 months, his kidney values have slowly been creeping up (last bloodwork in March: BUN 51, Creat 2.5, USG: 1.027). Ultrasound of his kidneys showed CKD, urine cultures have always been negative. Also, over the past 6 months, there has been a mass growing on his nasal planum, and he began sneezing blood. It was biopsied by another hospital and returned as a neutrophilic dermatitis. I was concerned that they did not get an adequate sample, so I performed radiographs which revealed bone lysis, and I performed an FNA through the lytic area on the nasal planum, revealing purulent discharge. Cytology revealed neutrophilic inflammation, no pathogens, and bacterial and fungal cultures returned as negative. Serology for Crypto also negative. I recommended explore (although I was not very excited about anesthetizing a diabetic CKD cat) +/- resubmission of samples. We kept the cat on fluids all day, and performed the procedure with no complications. The nasal sinus was opened, revealing complete destruction of all turbinates, and a huge amount of grey/green discharge was flushed out. Cytology was resubmitted, now revealing a large amount of branching fungal hyphae, very likely Aspergillus. The owner is tired of submitting tests at this point and not very excited about re-submitting for culture, and I am comfortable moving forward with the diagnosis of nasal Aspergillus as well without waiting another potential month for the culture results.
My question is: what would be the best therapy for this cat? I don't want to have to anesthetize him again for the clotrimazole topical therapy, but I also worry about putting him on chronic antifungal therapy because of his kidneys. Any thoughts?
Thanks! | Would posaconazole be an option? | Age? |
Hi,
I have an an approximately 12 year old male neutered DSH (weight 33.8 lbs) that presented for aural hematoma 2 weeks ago (left ear; scarred right ear as well from a prior hematoma). The owner declined surgical repair due to costs, and we decided against steroid therapy due to concern for it leading to diabetes in this cat with his severe obesity. We attempted a catheter as drain system in the pinna, which was working well until the cat got the e-collar off several days later. We treated for the underlying otitis (ear cytology showed 1+ rods and cocci AU) with TrizEDTA solution and Baytril Otic. The cat was on put on a course of Zeniquin. We also started him on Hills Metabolic Diet to attempt weight reduction.
On recheck, the pinned is now scarred and the ear cytology is now worse than before with 2+ rods and cocci AU. I was thinking of using a recipe for a TrizEDTA/Baytril injectable/Dexamethasone SP, but am still concerned about even this topical steroid making him more susceptible to DM. I was looking at relevant posts on VIN about systemic absorption of steroid and it looks like there are mixed opinions. Are there any topical steroid containing ear meds that are absorbed less systemically which may be safer? Any suggestions for this cat would be greatly appreciated.
Thank you! | Is his bloodwork normal? | What brand is the glucometer? |
I have a Female spayed, 9yr old Chihuahua/Terrier mix, Panda Puff, weighing 11.5 lbs. Presented 2/19/13 with a 2 month history of PU/PD and a 2 lb weight loss from 12/31/12. Owner thought appetite was stable (lives to eat). UA showed 2+ glucose, no ketones. Urine culture negative. Profile glucose = 494, alk phos 657, other values normal (cPL not run).
Kept in hosp 5 days, regulated on 6 u Humulin N BID, then boarded for a week, sent home on 6 u on 3/4/13.
Glucose curve on day 4 with 6 u admin 8:15AM, fed 1/3 can W/D + 4oz dry W/D at 8:16 =
8:15 bG= 171 10:30 bG= 83 12;00 bG= 114 2:00 bG= 124 4:00 bG= 177
Returned 3/13/13 for follow up curve. Hum N 6 u BID,W/D as above, plus O gave a few green beans as treat. Water intake stable, PU/PD much improved, owner happy.
8:45 bg 116 11:00 bg 71 2:00 bg 147 4:00 bg 190
dropped insulin to 5 u BID due to bg = 71 (better a little high than a little low)
Returned 4/15/13 Appetite low in morning for last 3 days, no other abnormalities seen by O, water intake stable per owner. 5 u BID, W/D as above, but O adding green beans and carrots. Panda gained .6 lbs.
9:00 bg 61 10:00 bg 41 fed additional W/D 11:30 bg 57 D/C'd curve, O to give 4 units Hum N PM and return next day for us to feed and admin insulin in AM
Returned 4/16/13 O fed W/D at home (ate well) and we gave 4 u Hum N in hosp.
8:40 bg 87 10:00 bg 68 12:00 bg 48 2:00 bg 31 fed 4:00 bg 182 Panda appeared normally responsive throughout stay, HR, mm, resp. stable throughout. Happy, bright, tail wagging. No neuro signs at any time.
Home on 2 units Humulin N BID, feeding as above.
This appears to be a possible resolving pancreatitis. Read about it, never seen it before. Open to other thoughts, suggestions. (Yes, I know I probably should have fed her at 12, instead of 2, and that it was pushing things to send her home on the 4 units in PM on the 15th. Sorry, looking back, probably would have done it differently. But Panda happy, tail wagging at all times.)
Thanks, | Absolutely sure that she's spayed? | What is the owner's objection to learning to generate the curves at home? |
I seem to be a magnet for atypical endocrine cases. The latest....
10-yr old Fe-sp Husky w/ typical endocrine alopecia (failure to regrow truncal hair after shaving last year, normal haircoat head/tail/legs) and severe pu/pd which PRECEEDED the development of diabetes. Cushing's testing negative (except for UCC).
Hx Details:
1/13 Pyuria, UrSG 1.008, neg glucose and BG, ALP 445, T4 low normal, Chol n (216), UCC ratio 18 (n14)
Dog acting normal
A) UTI, Cushings suspected, responsive to AB's
4/3 Worsening PU/PD, weight loss, glucosuria, BG 497. Dog acting normal other than pu/pd. ACTH Stim w/ 1 vial Cortrosyn and 1 hr post: 2.1-->11.3
4/12 insulin started (8 units/68lb-I know, very low). O was feeding large mid-day meal despite our feeding recommendations
4/15 Ultrasound revealed no adrenamegaly (from experienced internist)
4/16 Gluc curve 497 --> >600 2-8 hrs after insulin. Dog still "normal" except for pu/pd. Dose increased to 16 U bid w/ TID feeding
4/17 Insulin increased to 20 units. No dent in pu/pd.
Owner is purchasing a glucometer for home monitoring, which we will use alongside a BG curve soon.
Q: How fast would you increase this dog's insulin dose, and to what magnitude would you increase it each time?
Q: At what point would you consider this dog insulin unresponsive (I know we are far from it at this time)?
Q: Any thoughts on the endocrine alopecia and pu/pd that preceeded the diabetes?
Thanks for your help. | Culture? | In the meantime, what to do with the methimazole? |
I seem to be a magnet for atypical endocrine cases. The latest....
10-yr old Fe-sp Husky w/ typical endocrine alopecia (failure to regrow truncal hair after shaving last year, normal haircoat head/tail/legs) and severe pu/pd which PRECEEDED the development of diabetes. Cushing's testing negative (except for UCC).
Hx Details:
1/13 Pyuria, UrSG 1.008, neg glucose and BG, ALP 445, T4 low normal, Chol n (216), UCC ratio 18 (n14)
Dog acting normal
A) UTI, Cushings suspected, responsive to AB's
4/3 Worsening PU/PD, weight loss, glucosuria, BG 497. Dog acting normal other than pu/pd. ACTH Stim w/ 1 vial Cortrosyn and 1 hr post: 2.1-->11.3
4/12 insulin started (8 units/68lb-I know, very low). O was feeding large mid-day meal despite our feeding recommendations
4/15 Ultrasound revealed no adrenamegaly (from experienced internist)
4/16 Gluc curve 497 --> >600 2-8 hrs after insulin. Dog still "normal" except for pu/pd. Dose increased to 16 U bid w/ TID feeding
4/17 Insulin increased to 20 units. No dent in pu/pd.
Owner is purchasing a glucometer for home monitoring, which we will use alongside a BG curve soon.
Q: How fast would you increase this dog's insulin dose, and to what magnitude would you increase it each time?
Q: At what point would you consider this dog insulin unresponsive (I know we are far from it at this time)?
Q: Any thoughts on the endocrine alopecia and pu/pd that preceeded the diabetes?
Thanks for your help. | Tid feeding is not helping....has a curve been done? | Is she still autoagglutinating on slides? |
Hello,
I have recently become involved in an on-going case at my practice involving an insulin resistant cat. I'm a recent grad (2012) and I'd love any advice that I can get to help me work through this.
The cat is a 10yo F/S DSH weighing 3.9kg. Diabetes was originly diagnosed in October 2011. The abnorm findings on bloodwork at that time were as follows (T4 was well within norm range):
Glucose 21.5 (4.0 - 8.0) mmol/L
Creatinine 64 (71 - 203) umol/L
Chloride 101 (111 - 125) mmol/L
Anion Gap 36.6 (12 - 26) br/bumin 35 (23 - 33) g/L
ALT 167 (28 - 76) IU/L
Amylase 411 (463 - 1833) IU/L
Cholesterol 8.51 (2.00 - 6.00) mmol/L
Urinysis 3 glucosuria, USG 1.040, otherwise NAF on u/a
Fructosamine 510 (191 - 349) umol/L
The attending vet at that time started the cat on 1 unit glargine BID.
In January 2012, an in-clinic blood glucose curve was performed with the following results:
8am = BG 15.7mmol/L (fed) - did not eat right away so did not give insulin until 9:45
BG 11:30 = 20.2mmol/L
BG 3pm = 11mmol/L.
BG 6pm = 7.3mmol/L
BG 8pm = 9.9mmol/L
Based on these results, the cat was kept at 1 unit glargine BID and the owner was taught how to do BG curves at home for monitoring in the future.
In February 2012, things started to look different. The owner had acquired a glucose meter and began performing BG curves at home to minimize the impact of stress hyperglycemia and decrease costs of monitoring. Based on the following results, insulin was increased to 2 IU BID.
8am - 16.2
10am - 16.7
12....missed
2pm - 27.2
4pm - 22.2
6pm - 19.2
8pm - 15.2
10pm - 15.7
Then April 2012. The attending vet at the time double checked insulin handling, etc. Glargine was found to have expired, so a new vi was acquired and instructions for a repeat BG curve in two weeks.
8am before feeding and injection - 21.9
11am- 18.8
1:30 - 24.1
3:30 - 24.1
6pm 24.9 Before feeding and injection
8pm 23.1
9pm - 23.3
10pm - 22.1
After another similar curve to the one above, the dose was increased to 3IU glargine BID. Another curve following the dose change showed no change. At this point, the attending vet changed from glargine to Caninsulin 2IU BID (June 2012). Between January and June, the cat's weight increased from 3.4 to 4.5kg.
A curve in July was similar to the previous sever. After that point, there is a lag in the history where the Caninsulin was refilled as needed, the owner stopped submitting BG curves. Then in March 2013, when the owner complained that the cat was urinating a lot and the urine smelled bad. The cat had decreased in weight from 4.5kg in June 2012 to 3.9kg. The insulin dose was confirmed as still being 2IU BID of Caninsulin and a curve was performed (by the client) with similar results.
At this point a full panel with u/a and fructosamine was performed with the following results out of range (T4 was well within the norm range):
Glucose 16.4 (4.0 - 8.0) mmol/L
Chloride 103 (111 - 125) mmol/L
Anion Gap 33.5 (12 - 26) br/bumin 39 (23 - 33) g/L
ALT 129 (28 - 76) IU/L
Cholesterol 7.05 (2.00 - 6.00) mmol/L
Fructosamine 534 (191 - 349) umol/L
RBC 11.0 (6.0 - 10.0) x10E12
Hemoglobin 155 (95 - 150) g/L
Mean Corp Vol. 40.7 (41 - 58) fl
Urinysis: 3+ glucosuria, USG 1.062, trace protein
This is the point at which I came in, as I was the only vet on the day that these lab results arrived. So I read through the history and spoke to owner about the results. We increased to 3IU Caninsulin BID and had the owner perform another curve in 2-3 weeks, with similar results as the sever previous. One of the previous attending vets looked at the curve, spoke with me about it, we looked at the recommended dose range and decided we had room to move with the insulin dose before we cled the cat insulin resistant. So we increased to 3.5 IU BID, performed another curve and same thing. We reviewed insulin handling and storage once again, confirmed that 3.5IU is the actu dose being administered.
The most recent curve is as follows (April 2013):
8:00 am feeding
1030 - 16.4
2:00 - 22.9
5:00 feeding
8:30 pm 16.4
Thomas Graves ACVIM described insulin resistance as dosages increasing above 2-2.5 IU/kg (WVC 2013). So, we're most to that point now with the tot daily dose. We performed a urine cortisol:creatinine ratio to try and rule out hyperadrenocorticism, and it was norm. My plan at this point is to try and convince the owner to go to an intern medicine speciist, but I'm not sure if the owner will go. If you've made it through l of this very long post, I thank you sincerely and ask you if you have any advice on next steps for this cat?
Thank you very much for any advice you can offer. | I guess my first question is: do we know the owner's glucometer is accurate? | Could you first tell us what the insulin concentrations were and the blood glucose values at the exact time of those insulin values (+ reference ranges)? |
Hello,
I have recently become involved in an on-going case at my practice involving an insulin resistant cat. I'm a recent grad (2012) and I'd love any advice that I can get to help me work through this.
The cat is a 10yo F/S DSH weighing 3.9kg. Diabetes was originly diagnosed in October 2011. The abnorm findings on bloodwork at that time were as follows (T4 was well within norm range):
Glucose 21.5 (4.0 - 8.0) mmol/L
Creatinine 64 (71 - 203) umol/L
Chloride 101 (111 - 125) mmol/L
Anion Gap 36.6 (12 - 26) br/bumin 35 (23 - 33) g/L
ALT 167 (28 - 76) IU/L
Amylase 411 (463 - 1833) IU/L
Cholesterol 8.51 (2.00 - 6.00) mmol/L
Urinysis 3 glucosuria, USG 1.040, otherwise NAF on u/a
Fructosamine 510 (191 - 349) umol/L
The attending vet at that time started the cat on 1 unit glargine BID.
In January 2012, an in-clinic blood glucose curve was performed with the following results:
8am = BG 15.7mmol/L (fed) - did not eat right away so did not give insulin until 9:45
BG 11:30 = 20.2mmol/L
BG 3pm = 11mmol/L.
BG 6pm = 7.3mmol/L
BG 8pm = 9.9mmol/L
Based on these results, the cat was kept at 1 unit glargine BID and the owner was taught how to do BG curves at home for monitoring in the future.
In February 2012, things started to look different. The owner had acquired a glucose meter and began performing BG curves at home to minimize the impact of stress hyperglycemia and decrease costs of monitoring. Based on the following results, insulin was increased to 2 IU BID.
8am - 16.2
10am - 16.7
12....missed
2pm - 27.2
4pm - 22.2
6pm - 19.2
8pm - 15.2
10pm - 15.7
Then April 2012. The attending vet at the time double checked insulin handling, etc. Glargine was found to have expired, so a new vi was acquired and instructions for a repeat BG curve in two weeks.
8am before feeding and injection - 21.9
11am- 18.8
1:30 - 24.1
3:30 - 24.1
6pm 24.9 Before feeding and injection
8pm 23.1
9pm - 23.3
10pm - 22.1
After another similar curve to the one above, the dose was increased to 3IU glargine BID. Another curve following the dose change showed no change. At this point, the attending vet changed from glargine to Caninsulin 2IU BID (June 2012). Between January and June, the cat's weight increased from 3.4 to 4.5kg.
A curve in July was similar to the previous sever. After that point, there is a lag in the history where the Caninsulin was refilled as needed, the owner stopped submitting BG curves. Then in March 2013, when the owner complained that the cat was urinating a lot and the urine smelled bad. The cat had decreased in weight from 4.5kg in June 2012 to 3.9kg. The insulin dose was confirmed as still being 2IU BID of Caninsulin and a curve was performed (by the client) with similar results.
At this point a full panel with u/a and fructosamine was performed with the following results out of range (T4 was well within the norm range):
Glucose 16.4 (4.0 - 8.0) mmol/L
Chloride 103 (111 - 125) mmol/L
Anion Gap 33.5 (12 - 26) br/bumin 39 (23 - 33) g/L
ALT 129 (28 - 76) IU/L
Cholesterol 7.05 (2.00 - 6.00) mmol/L
Fructosamine 534 (191 - 349) umol/L
RBC 11.0 (6.0 - 10.0) x10E12
Hemoglobin 155 (95 - 150) g/L
Mean Corp Vol. 40.7 (41 - 58) fl
Urinysis: 3+ glucosuria, USG 1.062, trace protein
This is the point at which I came in, as I was the only vet on the day that these lab results arrived. So I read through the history and spoke to owner about the results. We increased to 3IU Caninsulin BID and had the owner perform another curve in 2-3 weeks, with similar results as the sever previous. One of the previous attending vets looked at the curve, spoke with me about it, we looked at the recommended dose range and decided we had room to move with the insulin dose before we cled the cat insulin resistant. So we increased to 3.5 IU BID, performed another curve and same thing. We reviewed insulin handling and storage once again, confirmed that 3.5IU is the actu dose being administered.
The most recent curve is as follows (April 2013):
8:00 am feeding
1030 - 16.4
2:00 - 22.9
5:00 feeding
8:30 pm 16.4
Thomas Graves ACVIM described insulin resistance as dosages increasing above 2-2.5 IU/kg (WVC 2013). So, we're most to that point now with the tot daily dose. We performed a urine cortisol:creatinine ratio to try and rule out hyperadrenocorticism, and it was norm. My plan at this point is to try and convince the owner to go to an intern medicine speciist, but I'm not sure if the owner will go. If you've made it through l of this very long post, I thank you sincerely and ask you if you have any advice on next steps for this cat?
Thank you very much for any advice you can offer. | E.g. has there been one curve in the hospit, so we can compare the numbers (not just once but over the course of the day) on the owner's machine vs those on a machine that we know to be accurate in-house? | What should he weigh? |
Hello,
I have recently become involved in an on-going case at my practice involving an insulin resistant cat. I'm a recent grad (2012) and I'd love any advice that I can get to help me work through this.
The cat is a 10yo F/S DSH weighing 3.9kg. Diabetes was originly diagnosed in October 2011. The abnorm findings on bloodwork at that time were as follows (T4 was well within norm range):
Glucose 21.5 (4.0 - 8.0) mmol/L
Creatinine 64 (71 - 203) umol/L
Chloride 101 (111 - 125) mmol/L
Anion Gap 36.6 (12 - 26) br/bumin 35 (23 - 33) g/L
ALT 167 (28 - 76) IU/L
Amylase 411 (463 - 1833) IU/L
Cholesterol 8.51 (2.00 - 6.00) mmol/L
Urinysis 3 glucosuria, USG 1.040, otherwise NAF on u/a
Fructosamine 510 (191 - 349) umol/L
The attending vet at that time started the cat on 1 unit glargine BID.
In January 2012, an in-clinic blood glucose curve was performed with the following results:
8am = BG 15.7mmol/L (fed) - did not eat right away so did not give insulin until 9:45
BG 11:30 = 20.2mmol/L
BG 3pm = 11mmol/L.
BG 6pm = 7.3mmol/L
BG 8pm = 9.9mmol/L
Based on these results, the cat was kept at 1 unit glargine BID and the owner was taught how to do BG curves at home for monitoring in the future.
In February 2012, things started to look different. The owner had acquired a glucose meter and began performing BG curves at home to minimize the impact of stress hyperglycemia and decrease costs of monitoring. Based on the following results, insulin was increased to 2 IU BID.
8am - 16.2
10am - 16.7
12....missed
2pm - 27.2
4pm - 22.2
6pm - 19.2
8pm - 15.2
10pm - 15.7
Then April 2012. The attending vet at the time double checked insulin handling, etc. Glargine was found to have expired, so a new vi was acquired and instructions for a repeat BG curve in two weeks.
8am before feeding and injection - 21.9
11am- 18.8
1:30 - 24.1
3:30 - 24.1
6pm 24.9 Before feeding and injection
8pm 23.1
9pm - 23.3
10pm - 22.1
After another similar curve to the one above, the dose was increased to 3IU glargine BID. Another curve following the dose change showed no change. At this point, the attending vet changed from glargine to Caninsulin 2IU BID (June 2012). Between January and June, the cat's weight increased from 3.4 to 4.5kg.
A curve in July was similar to the previous sever. After that point, there is a lag in the history where the Caninsulin was refilled as needed, the owner stopped submitting BG curves. Then in March 2013, when the owner complained that the cat was urinating a lot and the urine smelled bad. The cat had decreased in weight from 4.5kg in June 2012 to 3.9kg. The insulin dose was confirmed as still being 2IU BID of Caninsulin and a curve was performed (by the client) with similar results.
At this point a full panel with u/a and fructosamine was performed with the following results out of range (T4 was well within the norm range):
Glucose 16.4 (4.0 - 8.0) mmol/L
Chloride 103 (111 - 125) mmol/L
Anion Gap 33.5 (12 - 26) br/bumin 39 (23 - 33) g/L
ALT 129 (28 - 76) IU/L
Cholesterol 7.05 (2.00 - 6.00) mmol/L
Fructosamine 534 (191 - 349) umol/L
RBC 11.0 (6.0 - 10.0) x10E12
Hemoglobin 155 (95 - 150) g/L
Mean Corp Vol. 40.7 (41 - 58) fl
Urinysis: 3+ glucosuria, USG 1.062, trace protein
This is the point at which I came in, as I was the only vet on the day that these lab results arrived. So I read through the history and spoke to owner about the results. We increased to 3IU Caninsulin BID and had the owner perform another curve in 2-3 weeks, with similar results as the sever previous. One of the previous attending vets looked at the curve, spoke with me about it, we looked at the recommended dose range and decided we had room to move with the insulin dose before we cled the cat insulin resistant. So we increased to 3.5 IU BID, performed another curve and same thing. We reviewed insulin handling and storage once again, confirmed that 3.5IU is the actu dose being administered.
The most recent curve is as follows (April 2013):
8:00 am feeding
1030 - 16.4
2:00 - 22.9
5:00 feeding
8:30 pm 16.4
Thomas Graves ACVIM described insulin resistance as dosages increasing above 2-2.5 IU/kg (WVC 2013). So, we're most to that point now with the tot daily dose. We performed a urine cortisol:creatinine ratio to try and rule out hyperadrenocorticism, and it was norm. My plan at this point is to try and convince the owner to go to an intern medicine speciist, but I'm not sure if the owner will go. If you've made it through l of this very long post, I thank you sincerely and ask you if you have any advice on next steps for this cat?
Thank you very much for any advice you can offer. | Which diet is this kitty on? | How long is the cat going to board with you? |
Need some fresh 'eyes' on this one please.
12yr M/C Bengal
day 0
present owner's have had cat for 6 yrs (came to them as a neighborhood stray)
they say cat has always urinated outside of litterbox and had severe upper respiratory congestion with nose rubbing. cat sleeps under covers a lot. otherwise pretty happy and cool cat. Previous treatment with antibiotics had no effect on URI/congestion. hasn't gotten worse over the years, but not better either.
initial PE:
thickened crusted over nares with subsequent smaller ameter to nostrils, entire bridge of nose is thickened from years of rubbing
mild - moderate dental sease
sensitive around head/face handling and sensitive to bright light
else WNL
initial labs (Idexx sr screen)
increased Eosinophils
UTI
rest of cbc/chem/t4- wnl
felv/fiv- negative
whole body rads-wnl
day 3
general anesthesia
able to clean away crusts from thickened nares to reveal opening large enough for 4mm ear cone access.
looking at top of soft palate via endoscope shows uniform cobblestone appearance no masses identified.
nasal exam- copious amounts of purulent mucoid exudate. tissues bleed easily. no masses seen. most tissue eaten away and friable. bone exposed in many places.
dental and skull rads- no bone lysis in sinuses, many fully or mostly resorbed tooth roots (maxilla and mable), fractured crowns, resorptive lesions
culture from deep in nasal sinus- Staph aureus; sensitive to everything
biopsy of nasal tissue- eosinophillic plasmocytic ulcerative rhinitis
fungal cultures and cytology- negative
removed crowns of involved teeth with otherwise resorbed roots, a few extractions, clean and polish teeth
flushed nasal sinuses with luted chlorhex solution followed by sterile saline solution
started cat on DexSP, Baytril, Buprinex (all SQ inj as cat won't tolerate PO meds being given).
great initial response. Cat now urinating in litter box. Stopped sneezing and rubbing nose. Hardly congested. Sleeping out of covers no problem with rect light. More interactive and energetic.
2 weeks later
3 days after stopping 10 day course of Baytril. owner reported that cat is now rubbing at Right side of mouth after eating, like he has pain or food stuck between teeth. also, Right eye is now swollen. otherwise, seems ok.
recheck PE:
Right eye severe chemosis, minimal hyperemia, globe ok, negative flouroscein stain. no FB seen. no gum swelling or redness, teeth appear normal, non painful to touch gums or teeth, no pain on opening mouth, nothing visible between teeth and gums.
normal temp
rest of PE wnl
put cat back on Baytril
Gentocin ophth drops
warm compress over Right eye
4 days later, cat dn't allow much tx with the Gent ophth drops, but eye swelling is 85% better. both eyes are tearing excessively. cat is still pawing at Right side of mouth, especially when eating. and now sleeping under covers again. sounng more congested again.
Day 21 after initial procedure and starting of treatments
recheck PE. no change/wnl
resedated cat for recheck dental and sinus rads- except for possible small dark 'halo' around tip of upper PM4 cranial tooth root causing 'egg shell' appearance, no visible abnormalities or changes noted from before
still no occular FB (chemosis is 95% resolved)
no pockets identified when probing around teeth/gingiva
sensitive spot identified on caudal aspect of upper Right PM3 just under gumline. similar reaction on Left side but not as pronounced
removed upper Right PM2, PM3 and PM4 . Removed upper Left PM3 and lower PM 2 (exposed portion of root scovered). these teeth all came out more easily than normal.
retropulsion of both globes produces normal and equal intraoral response behind molars on both sides (no evidence of retrobulbar abscess)
hoping/suspecting that folowing initial dental and treatment for EP rhinitis, the now decreased gingival inflamation and removal of dental tartar, exposed the sensitive part of PM3 causing cat's scomfort and actions (pawing at mouth) and subsequent infection resulting in periorbital swelling.
3 days after second procedure
owner reports cat sounds more congested than before though not really sneezing or having nasal scharge
no periorbital swelling or chemosis but cat is now keeping eyes closed
still excessive tearing from both eyes
now pawing a bit at Left side of mouth
just wants to sleep now
now acting like he doesn't feel as well as before (before any previous procedures or after first one)
still eating and using litterbox
have owners reinstituting 'steam therapy' to help loosen sinus secretions
warm compress and cleaning of face/eyes
stop buprinex for 1-3 doses to see if fference
some thoughts are:
osteomyelitis that Baytril is not covering (can consider change to Unasyn)
irritation and/or blocked tear ducts causing copious epiphora
changing pain (eg was soft tissue, now skeletal?)
another dz process new or not previously identified
Cat won't really allow PO meds.
SQ injectables work well
thank you for your input and thoughts | It sounds like you continued buprinorphine and baytril (hope i'm getting this correct from your history) but d the cat receive any more corticosteroids? | Also, could you give the owner link to owners of insulin treated pets? |
I have a 8 1/2 year old outdoor spayed female cat that I saw for a yearly 3/15/13. At the time the owner reported she seemed hungry all the time and had lost about a pound. We did bloodwork and all was normal including the pancreas and the thyroid except on the CBC the PCV was on the low end of normal at 30% and the eosinophils were 4127 (0-1500). We were unable to get a fecal sample at the time. The cat was treated for parasites with 5 days of fenbendazole. The owner reports the cat feels better and the weight has gone up about 1/2 pound. The CBC shows the PCV is now 44% and the eosinophils are still elevated but down to 2640. We were able to run a fecal recently which was negative. I was wondering if I should repeat the fenbendazole course again or have is it not been enough time for the eosinophils to go back completely to normal. Should I be looking for any other reason for the eosinophilia right now since the cat seems to be responding. I was planning on doing an u/s as the next step if the cat wasn't doing better and the bloodwork was still abnormal. Thanks, | Does this kitty have a history of vomiting of food, fluid and/or hair? | Are spinal reflexes normal? |
"Magic" is a 17 year old F/S DSH. She was diagnosed with early renal disease in March 2011 and DM in May 2012. She has been maintained well on k/d diet and 1.5 units Lantus insulin BID. Her last BG curve started at 330, nadir at 152 and then back to 362 when the next dose was due. Her weight has slowly been dropping from 10.5 pounds to 9.9 pounds (over past year). Her last two geriatric profiles have shown mild hypercalcemia and hypomagnesemia. In October, her abnormal results were:
Ca 12.2 (8.2-10.8)
Mg 1.3 (1.5-2.5)
Below is her full profile from earlier this week. Do I need to be concerned about the dropping magnesium? How low is too low? If so, what further testing or supplementation do you recommend? The calcium may be renal or may not. With the weight loss, is a calcium panel warranted or only if it continues to rise? Do you think either of these is related to the weight loss? Thank you!
Lab results (taken at 8 AM, insulin was given at 7:30 AM):
Superchem
CBC
Tests Results Ref. Range Units
Tests Results Ref. Range Units
Total Protein 6.7 5.2-8.8 g/dL
Albumin 3.8 2.5-3.9 g/dL
Globulin 2.9 2.3-5.3 g/dL
A/G Ratio 1.3 0.35-1.5 Ratio
AST (SGOT) 21 10-100 U/L
ALT (SGPT) 59 10-100 U/L
Alk Phosphatase 19 6-102 U/L
GGTP 5 1-10 U/L
Total Bilirubin 0.1 0.1-0.4 mg/dL
Urea Nitrogen 28 14-36 mg/dL
Creatinine 2.0 0.6-2.4 mg/dL
BUN/Creatinine Ratio 14 4-33 Ratio
Phosphorus 3.9 2.4-8.2 mg/dL
Glucose 287 (HIGH) 64-170 mg/dL
The Glucose concentration in this cat is >170 mg/dl. A fructosamine level may be helpful in characterizing the nature of this hyperglycemia and differentiating stress hyperglycemia from early or sub-clinical diabetes mellitus, particularly in obese and/or male cats and/or when hyperglycemia is persistent. Please use test code 85881 for this additional testing.
Calcium 11.2 (HIGH) 8.2-10.8 mg/dL
Magnesium 1.1 (LOW) 1.5-2.5 mEq/L
Sodium 151 145-158 mEq/L
Potassium 4.5 3.4-5.6 mEq/L
Na/K Ratio 34
Chloride 115 104-128 mEq/L
Cholesterol 155 75-220 mg/dL
Triglycerides 39 25-160 mg/dL
Amylase 1356 (HIGH) 100-1200 U/L
Lipase 37 0-205 U/L
CPK 105 56-529 U/L
WBC 6.4 3.5-16.0 103/µL
RBC 8.37 5.92-9.93 106/µL
Hemoglobin 13.5 9.3-15.9 g/dL
Hematocrit 38.0 29-48 %
MCV 45 37-61 fL
MCH 16.1 11-21 pg
MCHC 35.5 30-38 g/dL
Platelet Count 88 (LOW) 200-500 103/µL
Platelet count reflects the minimum number due to platelet clumping.
Platelet EST Adequate Adequate
Differential Absolute %
Neutrophils 5120 80 2500-8500 /uL
Bands 0 0 0-150 /uL
Lymphocytes (LOW) 640 10 1200-8000 /uL
Monocytes 128 2 0-600 /uL
Eosinophils 512 8 0-1000 /uL
Basophils 0 0 0-150 /uL
Test Requested Results Reference Range Units
Total T4
T4 1.8 0.8-4.0 ug/dL
Urinalysis
Collection Method
Cystocentesis
Color Yellow
Appearance Clear *Clear
Specific Gravity 1.019 1.015-1.060
pH 6.0 5.5-7.0
Protein Negative Neg
Glucose 3+ (HIGH) Neg
Result verified.
Ketone Negative Neg
Bilirubin Negative Neg
Blood Negative Neg
WBC None 0-3 HPF
RBC 0-1 0-3 HPF
Casts None Seen LPF
Crystals None Seen HPF
Bacteria None Seen None HPF
Squamous Epithelia 0-1 0-3 HPF
Heartworm Antibody (Feline)
Collection Method
Occult Heartworm Antibody (Feline) Negative | Is there a history of vomiting of food, fluid and/or hair? | Did the dog look anemic? |
Hello,
Melanie is a 10 yo FS DSH that I am treating for DM. She has had elevated glucose for 2 years, but the owners were trying to treat with DM and glipizide. Didn't work - recent fructosamine was quite high. Started glargine a few months ago on 1 unit BID (12 lbs). Responded well at the initial curve, so I recurved in a few weeks and her nadir was 60 with a high of 90! I went down to 0.5 units bid and today her curve was 139, 165, 118, 145, and 137. She eats ced purina DM exclusively.
I think she is going into remission - agreed? Few questions, as this is my first...
- she is scheduled for a dental on Tuesday due to some nasty resporptive lesions. Is this terrible timing? Should I reschedule? I am hesitant to, as the owner wants the painful teeth out.
- if you think i can proceed with the dental, skip insulin and food pre-op?
- when to stop insulin? Give it a few more weeks at this dose, or sooner? And then would urine glucotests be a good plan?
Thank you! | Has her diet changed as well - was she eating dry food before? | Anyone noted similar side effect? |
Hello!
Cozmo is a 7-year old male neutered Toy Poodle that presented to our hospital for evaluation of pu/pd. Bloodwork and urinalysis were consistent with diabetes. At the time of insulin administration demonstration to owner (3 days post-initial appointment), an ~1.5 inch soft SQ area of swelling was noted at the right angle of the mandible. His owners elected continued observation.
A blood glucose curve was performed approximately 1 month after initial diabetic diagnosis (still slightly unregulated). At this time, the swelling noted at the right angle of the mandible had doubled in size (still soft and nonpainful). An aspirate was performed (removed approximately 2 mL of hemorrhagic viscous fluid) and submitted for cytology (lymphocytic, histiocytic, neutrophilic inflammation associated with injured salivary gland or gland duct). Despite the increase in size, his owner has not noticed any changes in appetite, swallowing, or excessive salivation.
I know that treatment should involve placing Cozmo on steroids; however, I have a couple of questions. Should he be completely regulated before starting steroid treatment? Can I even start steroid treatment in a diabetic? Can a decreased steroid dose be used? Any thoughts or suggestions would be greatly appreciated. Thank you!
~ | Since this seems to be a fluid filled mass, it may be a sialocele rather than just inflammation of the salivary gland? | The owner moves the insulin injections around on his body every day? |
I have a 13 yr MC pekingnese X who has had diabetes for 7 years, and has been well controlled for at least the past 2 years. This past weekend he had hypoglycemic crisis and was at ER overnight, then he presented to us with a BG of 56 despite IV dextrose. We hospitalized him on 5% dex IV fluids and he was stable later that day with a sugar of 103. The owner monitored over the weekend--probably gave too much Karo syrup-and on Monday his glucose was 558,he had ketones in his urine, and was vomiting. After 24 hours of fluids and insulin, he was improved and discharged at 70% of his regular insulin dosage (Humulin N) bid. He has been fine per owner, possibly little lethargic, not pu/pd. This am a glucose was 149 prefood or insulin. We fed him, did not give insulin and ran a curve: 93, 233, 220, 122 (each 2 hours apart). The last dose of insulin was last night.
The dog's bloodwork is normal, his exam is normal (for him), and the owner has not changed anything. She did buy a new bottle of insulin around the time that all of this started. That is the only explanation that I can think of, but it is the same brand and it seems a stretch to believe that bottle would be different from the rest. What am I missing? | How long had the owner had the previous bottle? | Is he on humulin nph or novolin nph? |
I have a 13 yr MC pekingnese X who has had diabetes for 7 years, and has been well controlled for at least the past 2 years. This past weekend he had hypoglycemic crisis and was at ER overnight, then he presented to us with a BG of 56 despite IV dextrose. We hospitalized him on 5% dex IV fluids and he was stable later that day with a sugar of 103. The owner monitored over the weekend--probably gave too much Karo syrup-and on Monday his glucose was 558,he had ketones in his urine, and was vomiting. After 24 hours of fluids and insulin, he was improved and discharged at 70% of his regular insulin dosage (Humulin N) bid. He has been fine per owner, possibly little lethargic, not pu/pd. This am a glucose was 149 prefood or insulin. We fed him, did not give insulin and ran a curve: 93, 233, 220, 122 (each 2 hours apart). The last dose of insulin was last night.
The dog's bloodwork is normal, his exam is normal (for him), and the owner has not changed anything. She did buy a new bottle of insulin around the time that all of this started. That is the only explanation that I can think of, but it is the same brand and it seems a stretch to believe that bottle would be different from the rest. What am I missing? | Could it be that the owner is reconstituting the insulin better now? | Are they related? |
Hello! I have a patient that is confusing me. He is a 13 year old neutered male domestic long hair that weighs 13.72lbs. He is a diabetic that was diagnosed 2 months ago. His owner accidentally increased his dosage to 6 units of glargine bid and he did great! Decreased pu/pd, increased energy, etc... The owner realized her mistake and started giving his insulin accurately at 3 units bid 4-5 days ago. His urine volume increased and he is less energetic. He is eating a very consistent diet am and pm with no changes or treats during the day. The owner is giving his insulin correctly, it is the same bottle of glargine that she started with a couple of months ago, and she is rolling/not shaking the bottle. Today this cat came in for a blood glucose curve. His 3 units of glargine insulin was given at 6:50am. He ate his normal type and quantity of food. His blood glucose curve is the following: 8am 120, 10am 95, 12pm 133, 2pm 105, 5pm 92, 6pm 58. The glucose curve was performed in house. He is gaining weight and doing overall well. I am not sure what to tell the owner to do. This glucose curve makes me concerned to increase the insulin level despite his symptoms. No other reason can be determined that he would be feeling differently other than his insulin...ie no uti, etc.. He does have mild to moderate dental dz but nothing that appears overtly painful and is a very good cat/easily allows a full mouth exam while pressing on gingiva, etc.. Any recommendations would be most appreciated! Thank you! | Is he eating the canned-only version of a high protein/low carb diet? | What was her t4? |
Hello! I have a patient that is confusing me. He is a 13 year old neutered male domestic long hair that weighs 13.72lbs. He is a diabetic that was diagnosed 2 months ago. His owner accidentally increased his dosage to 6 units of glargine bid and he did great! Decreased pu/pd, increased energy, etc... The owner realized her mistake and started giving his insulin accurately at 3 units bid 4-5 days ago. His urine volume increased and he is less energetic. He is eating a very consistent diet am and pm with no changes or treats during the day. The owner is giving his insulin correctly, it is the same bottle of glargine that she started with a couple of months ago, and she is rolling/not shaking the bottle. Today this cat came in for a blood glucose curve. His 3 units of glargine insulin was given at 6:50am. He ate his normal type and quantity of food. His blood glucose curve is the following: 8am 120, 10am 95, 12pm 133, 2pm 105, 5pm 92, 6pm 58. The glucose curve was performed in house. He is gaining weight and doing overall well. I am not sure what to tell the owner to do. This glucose curve makes me concerned to increase the insulin level despite his symptoms. No other reason can be determined that he would be feeling differently other than his insulin...ie no uti, etc.. He does have mild to moderate dental dz but nothing that appears overtly painful and is a very good cat/easily allows a full mouth exam while pressing on gingiva, etc.. Any recommendations would be most appreciated! Thank you! | Which one? | Or has it been out walking around in the house? |
Hello! I have a patient that is confusing me. He is a 13 year old neutered male domestic long hair that weighs 13.72lbs. He is a diabetic that was diagnosed 2 months ago. His owner accidentally increased his dosage to 6 units of glargine bid and he did great! Decreased pu/pd, increased energy, etc... The owner realized her mistake and started giving his insulin accurately at 3 units bid 4-5 days ago. His urine volume increased and he is less energetic. He is eating a very consistent diet am and pm with no changes or treats during the day. The owner is giving his insulin correctly, it is the same bottle of glargine that she started with a couple of months ago, and she is rolling/not shaking the bottle. Today this cat came in for a blood glucose curve. His 3 units of glargine insulin was given at 6:50am. He ate his normal type and quantity of food. His blood glucose curve is the following: 8am 120, 10am 95, 12pm 133, 2pm 105, 5pm 92, 6pm 58. The glucose curve was performed in house. He is gaining weight and doing overall well. I am not sure what to tell the owner to do. This glucose curve makes me concerned to increase the insulin level despite his symptoms. No other reason can be determined that he would be feeling differently other than his insulin...ie no uti, etc.. He does have mild to moderate dental dz but nothing that appears overtly painful and is a very good cat/easily allows a full mouth exam while pressing on gingiva, etc.. Any recommendations would be most appreciated! Thank you! | Was uti ruled out with a urine culture? | Meaning, do the owners find the urine in the house when they've been gone all day and the dog doesn't have access to the outdoors, or first thing in the morning after everyone's been asleep and the dog has no access to the outdoors? |
Hey there, I'm looking for a little feedback on a glucose curve I did on a newly diagnosed diabetic. I am writing from home, so please excuse me if I am lacking a few details. I can get those Monday morning.
Andy is an 8 yr old mini poodle. Diagnosed two weeks ago with DM by my relief vet. Borderline ketoacidosis. She started him on 3 U of NPH BID. That was about a 0.35 U/kg dose for him. After one week, owner reported some mild improvement, but still pu/pd and peeing in the house. A pre-insulin BG was taken and was about 600 and so we increased to 4 units.
Another week went by which brought us to yesterday. Owner reported that Andy is doing much better. No more peeing in the house. Seems happier. Dropped off for a glucose curve. Results are below.
8:06: 192
10am: 84
11am: 159
12pm: 201
1pm: 185
3pm: 313
5p- not in record, but will have access on Monday. Was higher than 3p, naturally.
O had given insulin at 6:45 am. She feeds Royal Canin Diabetic canned food, which she started AFTER the first week. She does give him a few treats throughout the day and she brought those treats with him. They were to be given at 10a and 2p. We pulled the 10a sample prior to giving the treats, but after seeing the 84, we promptly gave them to him. It was three small kibbles of something. Not a big treat. We did NOT give the 2p treat to see what would happen.
I was surprised to see the nadir only 3 hours after getting the insulin. I am nervous about her being on this dose as who knows if the glucose would have gone lower if we hadn't given him those treats. My thoughts are to decrease to 3.5 units, but I suspect his pre-insulin glucose will be too high again. I assume this is because the NPH isn't lasting long enough? Would he be better on Vetsulin? I hear it's coming back out, but I have never used it. I really haven't used any other insulins than Glargine for cats and NPH for dogs. Any other thoughts?
Thanks for the help! | What are we talking about here exactly - hyperglycemia, glucose, ketones, acidosis, which factors were present? | Were the samples submitted to a commercial lab? |
7 yr M/N Lab Ret 118lbs
Previous Hx of MCT removed from R ear. Excision complete with 1.5cm margins.
Annual Exam 4/11/13 -no concerns per owner. I recommended weight loss. BCS 8/9 4dX-Negative x4. Vaccines-lepto, lyme (
Boehringer I, and merial. vaccinated with these vaccines 5 times prior), Rabies (Fort Dodge). On HG and Advantix
4/16/13- Intranasal Bordetella
4/20/13 Presented to the local emergency center for "eyes red and swollen with greenish discharge for starting 4/19/13" p was boarded at a home with seven other dogs for two nights. While there the patient only ate one time and had soem diarrhea one time. Within the past 24 hours dog had been drinking more but not prior.
On exam (at the Emergency Center)
General appearance: lethargic/weak temp 100.0 HR 100
Integumentary: generalized edema, prominent on face but noted over the whole body.
Musculoskeletal: pot bellied
Eyes: OU marked inflammation and mucopurulent discharge OD
Mucous Membranes: bright pink (owners remarked Orange color)
Hydration: tacky mm :5% dehydration
All other systmes WNL
CBC/Chemistry Full
Glucose 554 (74-143)
BUN 21 (7-27)
Alb 4.0 (2.3-4.0)
Hct 46.2 (37-55)
All others WNL
UA: USG 1.049,
Protein ++
Bacteria: rods+++ (not sure I believe this we have had conflicting results in the past)
WBC: 3-4 per 40X
Casts: n/a
pH: 6.0
Blood:neg
Ketone: trace
Glucose: 2000 or more
Sediment: no RBC/crystals/casts. occasional squamous cells.
IV Catheter, LRS at 160ml/hr
Ampicillin 44ml of 25mg/ml IV q8hrs
Baytril 136mg PO q 12hrs (initially 5.5ml of 2.27% IV)
Tobramycin OU q 8hrs
Humulin-R 5U IM Epaxial
Added 55U Humulin R to 120ml LRS Started CRI at 10ml/hr
Glucose Levels
5:30pm 566 (4/20)
6:00 608
7:15 501
8:30 454
9:30 306 Insulin drip decreased to 8ml/hr
10:00 311
11;00 290
1:00 am 229 (4/21) Insulin drip decreased to 7 ml/hr
3:00 165 decreased Insulin drip to 4ml/hr
5:30 221 Increased INsulin drip to 5ml/hr
7:00 198 Decreased to 4ml/hr
8:15 246 Increased to 6ml/hr Discontinued at 8:40am Administered 20U of Humulin N SQ Left Hind. Note that Edema is more pronounced.
11:00 418 SQ insulin not well absorbed due to edema restart CRI 6ml/hr
12 :00 432
2:27pm 379 Increased to 7ml/hr
7:00 403 Increased to 10ml/hr
8:30 467 increased to 12ml/hr
11:00 368
12:00 am 404 (4/22)
2:00am 344
4:00 365
6:30 342
He then presented to me
mild swelling around the muzzle, I would not have noticed if not pointed out. Still moderate injected sclera but no other ocular signs. UA: USG 1.022,Glucose 1000, Ketones neg. RBC/WBC neg. No abnormalities on sediment.
I continued the Ampicillin, Baytril, Tobramycin and Humulin R Insulin at 12ml/hr
Glucose levels
9:45am 459 (before drip)
12:30 560
1:30 431
3:00 658
4:00 652
Appetite has been great the whole time, no interest in water, average urination.
I have never seen a presentation of Diabetes without noticeable PU/PD first, so I'm wondering if something else could be going on? Was the edema secondary to the vaccines (lepto/lyme/rabies vs Bordetella)? Then this made the dog feel worse and magnifing the diabetes?
My thought is to try the Humulin N again since the regular doesn't seem to be helping, and I'm not sure I can increase that drip anymore. Or should I do IM injections of Humulin R?
I have discussed xrays/ultrasound but advised this would be looking for masses/cancers.
Wat else can I do for this dog? | Is there any chance that he was given any steroids while at the ec to treat the edema/vasculitis? | What does he currently weigh? |
We have a 7 1/2 year old F/S Austral Cattle Dog that is a classic Cushing's Dog. She is PU/PD, has a pendulous abdomen and more fat over the hunches, she pants like crazy even at rest, and is having recurrent UTI problems. Bloodwork all wnl except for Alk Phos (910).
Low Dose Dex Suppresion - resting 9.3
4 hour - 1.1
8 hour - 1.0
Not the greatest result to conclusively say the dog is cushnoid.
Where should I go from here, adrenal panel to Univ of Tenn, U/S referral (I can find the left, the right is a crap shoot), treat very carefully with lysodren? The owner is great but has many pets and is cost conscious (who isn't)
thanks, | No chance we accidentally did a hddst? | Does the owner feed a set amount of this food per day? |
We have a 7 1/2 year old F/S Austral Cattle Dog that is a classic Cushing's Dog. She is PU/PD, has a pendulous abdomen and more fat over the hunches, she pants like crazy even at rest, and is having recurrent UTI problems. Bloodwork all wnl except for Alk Phos (910).
Low Dose Dex Suppresion - resting 9.3
4 hour - 1.1
8 hour - 1.0
Not the greatest result to conclusively say the dog is cushnoid.
Where should I go from here, adrenal panel to Univ of Tenn, U/S referral (I can find the left, the right is a crap shoot), treat very carefully with lysodren? The owner is great but has many pets and is cost conscious (who isn't)
thanks, | So is treatment and appropriate monitoring going to be feasible? | Does this look consistent with a gdv or just dilation? |
Hello VIN Colleagues
I am struggling to regulate a diabetic patient.
Holly is a 4-5 year old female spayed Greyhound from Spain. On her first visit to the Naples Italy veterinary treatment facility last fall, we determined that she was heartworm positive. I treated her with a single Immiticide injection and 30 days of Doxycycline. One month later she received two Immiticide injections 24 hours apart. Holly was a good candidate for adulticide therapy and had no other issues besides urinary incontinence which was controlled with Proin. Her body condition was normal for a greyhound.
In January 2013, she presented with PU/PD, incontinence despite Proin, and weight loss. Her blood glucose level was 418. She had mild elevations in ALT, AlkPhos, GGT, and tBili. Her urine S.G. was 1.045 and she had +1 glucosuria. Attitude and appetite were excellent so I started her on Caninsulin (vetsulin) at 11U SQ BID. I also obtained a cysto urine sample for a culture which was positive, and treated her UTI with Clavamox.
Holly's February glucose curve:
301
11 U caninsulin with meal
314
190
170
230
275
301
At this point I increased her caninsulin dose to 13U BID. The recheck curve in March:
357
13 U caninsulin SQ with meal
241
87
80
140
248
317
411
I was concerned about potential somogyi effect so I reduced the insulin back down to 11 U BID especially since her owner had to travel and the pet sitter was not staying at her home. Holly's blood pressure was assessed and was normal. Recheck bloodwork revealed that her liver values were back in the reference range but now she had a mild anemia (HCT 34%). Calcium, TP, and Alb all mildly decreased.
I sent some blood smears off to the Lab in Germany, and the RBCs were reported as normochromic with no shape changes. No hints of regeneration and reticulocyte count of 11.2. Platelets appeared normal and in normal numbers. No intracellular organisms noted. CHR = 24.9 so iron deficiency unlikely.
An Italian colleague performed an abdominal ultrasound and no abnormalities were detected. Her recheck urine culture was negative.
Holly's owner had to travel again, so she was in the care of a pet sitter. Today her curve is:
415
11 U Caninsulin SQ with meal
515
310
360
362
471
393
She is still eating well but has lost 20 lbs over the past 6 months. Her mild non-regenerative anemia is unchanged and she is dehydrated.
My next steps include:
(1) change insulin.
(2) ACTH stim to rule out Cushings even though blood chemistry is not suggestive.
(3) bone marrow aspirate.
Thank you for your input | Are we absolutely sure she's spayed? | While on or before methimazole? |
Hello VIN Colleagues
I am struggling to regulate a diabetic patient.
Holly is a 4-5 year old female spayed Greyhound from Spain. On her first visit to the Naples Italy veterinary treatment facility last fall, we determined that she was heartworm positive. I treated her with a single Immiticide injection and 30 days of Doxycycline. One month later she received two Immiticide injections 24 hours apart. Holly was a good candidate for adulticide therapy and had no other issues besides urinary incontinence which was controlled with Proin. Her body condition was normal for a greyhound.
In January 2013, she presented with PU/PD, incontinence despite Proin, and weight loss. Her blood glucose level was 418. She had mild elevations in ALT, AlkPhos, GGT, and tBili. Her urine S.G. was 1.045 and she had +1 glucosuria. Attitude and appetite were excellent so I started her on Caninsulin (vetsulin) at 11U SQ BID. I also obtained a cysto urine sample for a culture which was positive, and treated her UTI with Clavamox.
Holly's February glucose curve:
301
11 U caninsulin with meal
314
190
170
230
275
301
At this point I increased her caninsulin dose to 13U BID. The recheck curve in March:
357
13 U caninsulin SQ with meal
241
87
80
140
248
317
411
I was concerned about potential somogyi effect so I reduced the insulin back down to 11 U BID especially since her owner had to travel and the pet sitter was not staying at her home. Holly's blood pressure was assessed and was normal. Recheck bloodwork revealed that her liver values were back in the reference range but now she had a mild anemia (HCT 34%). Calcium, TP, and Alb all mildly decreased.
I sent some blood smears off to the Lab in Germany, and the RBCs were reported as normochromic with no shape changes. No hints of regeneration and reticulocyte count of 11.2. Platelets appeared normal and in normal numbers. No intracellular organisms noted. CHR = 24.9 so iron deficiency unlikely.
An Italian colleague performed an abdominal ultrasound and no abnormalities were detected. Her recheck urine culture was negative.
Holly's owner had to travel again, so she was in the care of a pet sitter. Today her curve is:
415
11 U Caninsulin SQ with meal
515
310
360
362
471
393
She is still eating well but has lost 20 lbs over the past 6 months. Her mild non-regenerative anemia is unchanged and she is dehydrated.
My next steps include:
(1) change insulin.
(2) ACTH stim to rule out Cushings even though blood chemistry is not suggestive.
(3) bone marrow aspirate.
Thank you for your input | How much does she weigh? | Would the owners treat with chemo if this was lymphoma and surgery wasn't required? |
Hello VIN Colleagues
I am struggling to regulate a diabetic patient.
Holly is a 4-5 year old female spayed Greyhound from Spain. On her first visit to the Naples Italy veterinary treatment facility last fall, we determined that she was heartworm positive. I treated her with a single Immiticide injection and 30 days of Doxycycline. One month later she received two Immiticide injections 24 hours apart. Holly was a good candidate for adulticide therapy and had no other issues besides urinary incontinence which was controlled with Proin. Her body condition was normal for a greyhound.
In January 2013, she presented with PU/PD, incontinence despite Proin, and weight loss. Her blood glucose level was 418. She had mild elevations in ALT, AlkPhos, GGT, and tBili. Her urine S.G. was 1.045 and she had +1 glucosuria. Attitude and appetite were excellent so I started her on Caninsulin (vetsulin) at 11U SQ BID. I also obtained a cysto urine sample for a culture which was positive, and treated her UTI with Clavamox.
Holly's February glucose curve:
301
11 U caninsulin with meal
314
190
170
230
275
301
At this point I increased her caninsulin dose to 13U BID. The recheck curve in March:
357
13 U caninsulin SQ with meal
241
87
80
140
248
317
411
I was concerned about potential somogyi effect so I reduced the insulin back down to 11 U BID especially since her owner had to travel and the pet sitter was not staying at her home. Holly's blood pressure was assessed and was normal. Recheck bloodwork revealed that her liver values were back in the reference range but now she had a mild anemia (HCT 34%). Calcium, TP, and Alb all mildly decreased.
I sent some blood smears off to the Lab in Germany, and the RBCs were reported as normochromic with no shape changes. No hints of regeneration and reticulocyte count of 11.2. Platelets appeared normal and in normal numbers. No intracellular organisms noted. CHR = 24.9 so iron deficiency unlikely.
An Italian colleague performed an abdominal ultrasound and no abnormalities were detected. Her recheck urine culture was negative.
Holly's owner had to travel again, so she was in the care of a pet sitter. Today her curve is:
415
11 U Caninsulin SQ with meal
515
310
360
362
471
393
She is still eating well but has lost 20 lbs over the past 6 months. Her mild non-regenerative anemia is unchanged and she is dehydrated.
My next steps include:
(1) change insulin.
(2) ACTH stim to rule out Cushings even though blood chemistry is not suggestive.
(3) bone marrow aspirate.
Thank you for your input | Can you post the actual results for the cbc/chem screen---when were these done? | What exactly were the numbers for na and k? |
Eloise is an 8yr old FN Burmese cat. At 5yrs of age, eloise developed severe ulcerative stomatitis and gingivitis. All her teeth (except canines) were extracted and her stomatiis controlled with topical triamcimalone gel. The gums healed and Eloise continued to thrive.
At 6.5 yrs of age she developed abetes melitus and commenced treatment with glargine (Lantus) insulin - twice daily at 2U. She was fed canned m/d. Over the following year, her abetes was controlled and she went into remission and d not need insulin for over 8 mths.
Last month, the owner noticed a return to pd/pu and testing revealed elevated blood glucose. Glargine was restarted at 0.5U and gradually increased to 2U, the o was urine testing at home and noticed an increase in the urine glucose.
She had an episode of acute vomiting and it was found that she had pancreatitis and elevated urea with inappropriately lute urine (1.020) when 8% dehydrated.
She responded to symptomatic treatement of IV fluids. Today Eloise relapsed and today her urea is 39mmol/l(elevated) , glucose 22.8mmol/l. Creatinine 121 mmol/l(normal) .The urine has 4+ glucose and trace ketone. USG 1.020 . Awaiting fpL.
Ultrasound at the last episode confirmed inflammation (hypercoic) changes adjacent to the pancreas but an otherwise normal abdo.
Treatment:
convenia (cefovecin) injection monthly for conrol of stomatitis
vit b12 injection monthly
benazapril 2.5mg sid (her BP was 180-200mm Hg)
lantus 3u bid
cerenia injection.
Methadone 0.6mg/kg sq.
Qestions:
the urine is inappropriately lute for the degree of dehydration and the urea is elevated. Does glucosuria - artificially elevated the USG?
Is the urine really much closer to isosthenuric? With this in mind, can we tell pre renal from renal azotemia?
What measures can be used to prevent chronic pancreatitis?
I have read through the message board, and it seems my only option now is cerenia as needed and try metronidaole.
How common is toxoplasmosis in pancreas?
Is immune meated pancreatitis an issue in cats. if so, should pred be used in a abetic cat?
Is the chronic recurrent pancreatitis why our insulin levels are neeng to be continuously increased, or is it the dehydration associated with renal sease etc, leang to insulin resistance?
Her current et is: k/d canned followed by m/d canned and ocassionally a/d dependent on her appetite.
The owner has offered to purchase me a botox voucher at the local cosmetic surgeon because her cat is making me frown so much!! Please help.. | Q:how common is toxoplasmosis in pancreas? | Is he eating the canned version of the dm diet? |
Eloise is an 8yr old FN Burmese cat. At 5yrs of age, eloise developed severe ulcerative stomatitis and gingivitis. All her teeth (except canines) were extracted and her stomatiis controlled with topical triamcimalone gel. The gums healed and Eloise continued to thrive.
At 6.5 yrs of age she developed abetes melitus and commenced treatment with glargine (Lantus) insulin - twice daily at 2U. She was fed canned m/d. Over the following year, her abetes was controlled and she went into remission and d not need insulin for over 8 mths.
Last month, the owner noticed a return to pd/pu and testing revealed elevated blood glucose. Glargine was restarted at 0.5U and gradually increased to 2U, the o was urine testing at home and noticed an increase in the urine glucose.
She had an episode of acute vomiting and it was found that she had pancreatitis and elevated urea with inappropriately lute urine (1.020) when 8% dehydrated.
She responded to symptomatic treatement of IV fluids. Today Eloise relapsed and today her urea is 39mmol/l(elevated) , glucose 22.8mmol/l. Creatinine 121 mmol/l(normal) .The urine has 4+ glucose and trace ketone. USG 1.020 . Awaiting fpL.
Ultrasound at the last episode confirmed inflammation (hypercoic) changes adjacent to the pancreas but an otherwise normal abdo.
Treatment:
convenia (cefovecin) injection monthly for conrol of stomatitis
vit b12 injection monthly
benazapril 2.5mg sid (her BP was 180-200mm Hg)
lantus 3u bid
cerenia injection.
Methadone 0.6mg/kg sq.
Qestions:
the urine is inappropriately lute for the degree of dehydration and the urea is elevated. Does glucosuria - artificially elevated the USG?
Is the urine really much closer to isosthenuric? With this in mind, can we tell pre renal from renal azotemia?
What measures can be used to prevent chronic pancreatitis?
I have read through the message board, and it seems my only option now is cerenia as needed and try metronidaole.
How common is toxoplasmosis in pancreas?
Is immune meated pancreatitis an issue in cats. if so, should pred be used in a abetic cat?
Is the chronic recurrent pancreatitis why our insulin levels are neeng to be continuously increased, or is it the dehydration associated with renal sease etc, leang to insulin resistance?
Her current et is: k/d canned followed by m/d canned and ocassionally a/d dependent on her appetite.
The owner has offered to purchase me a botox voucher at the local cosmetic surgeon because her cat is making me frown so much!! Please help.. | Q:is the chronic recurrent pancreatitis why our insulin levels are neeng to be continuously increased, or is it the dehydration associated with renal sease etc, leang to insulin resistance? | The $64k question is: how do we treat pancreatitis in cats? |
Morning,
Max is a 5 yr old MN DSH, diagnosed with eosinophilic IBD via cytology Dec 2010. He also had eosinophilia [20,520 (0-1000)]. Had history of chronic vomiting and 3 lb wt loss. Has been doing well on prednisolone 5 mg daily. Had gained back weight, no vomiting and circulating eos staying below 2000. Became symptomatic at lower dose of pred.
Well, Max presented yesterday for vomiting 2-3 times daily and 1 1/2 lb wt loss. Owner says vomiting started when she switched to a scented litter. Switched back to regular litter 36 hrs prior to yesterday's visit and Max hasn't vomited since.
PE unremarkable except for wt loss and temp 102.9
CBC - eos 1136 (0-1000)
chem -
alb - 4.0 (2.5-3.9)
ALT - 109 (10-100)
glucose - 418 (64-170)
T4 1.3
UA
SG 1.053
pH 5.5
glucose 3+
So, the vomiting may have been an allergic rxn to the litter. I'm not sure I'm convinced about that.
My question though is controlling the DM while on pred. Are there other options for the eosinophilic IBD? Or are we stuck with keeping Max on pred and just trying to control the DM with glargine?
Any suggestions?
Thanks, | Have you recently submitted a cobalamin on this kitty? | Is it the same every day? |
Tater is an 8 yr nm diabetic schnauzer. we have struggled to get him regulated. He weighs 19.2# and is currently on 15 u.
He also taked gemfibrozil 200 mg BID (just increased from q 24 hrs to q 12 hrs) and chitosan 500mg BID for his hypertriglyceridemia. ( 1333; normal 26-108)
He recently had cataract sx and has been doing well with this.
His urine cort: creat ratio is normal and his urine culture is neg.
The owner just told me that about 30-40 min after his insulin he is sleepy. She said he's always been like this; even before the gemfib/chitosan were started. I told her I'd check into this and see if this can happen short of inducing a low BG. its been a little while since we've done a curve but we check his insulin weekly at about 4 pm.
thoughts?
I was thinking the half-life of NPH was about 6 hrs; but peak onset was 2 hrs? I know this can vary. The owner says after he naps then he's up and fine. So it seems like he gets sleepy before the peak onset of insulin and will become perky AT the peak onset.
hmmm.
thoughts? curve?
Thanks, | What diet is he on? | Scraped for demodex? |
Tater is an 8 yr nm diabetic schnauzer. we have struggled to get him regulated. He weighs 19.2# and is currently on 15 u.
He also taked gemfibrozil 200 mg BID (just increased from q 24 hrs to q 12 hrs) and chitosan 500mg BID for his hypertriglyceridemia. ( 1333; normal 26-108)
He recently had cataract sx and has been doing well with this.
His urine cort: creat ratio is normal and his urine culture is neg.
The owner just told me that about 30-40 min after his insulin he is sleepy. She said he's always been like this; even before the gemfib/chitosan were started. I told her I'd check into this and see if this can happen short of inducing a low BG. its been a little while since we've done a curve but we check his insulin weekly at about 4 pm.
thoughts?
I was thinking the half-life of NPH was about 6 hrs; but peak onset was 2 hrs? I know this can vary. The owner says after he naps then he's up and fine. So it seems like he gets sleepy before the peak onset of insulin and will become perky AT the peak onset.
hmmm.
thoughts? curve?
Thanks, | Is the chitosan being given 30 minutes before each meal? | Is this being done? |
Duke is a 3-year old neutered male Boxer. In October 2011 he weighed 89 lb and that was the first time PU/PD was noted. I first saw him in Dec 2011 and he weighed 79 lb. I did a pre-operative blood panel on him and it was normal (CBC, BUN, Creat, ALT, ALP, glucose), USG 1.010. At that point, I thought there was a behavioral cause for him to drink a lot. His owner started to limit his water intake and over the next year, she said he did ok, as long as he didn't have access to too much water.
I saw him again in Jan 2013 because the PU/PD was again getting worse. Owner said he would do anything to get water - empty the toilet, push the water dispenser on the refrigerator, etc. I had his owner collect his first morning urine 5 days in a row. The USG on these samples was: 1.026, 1.028, 1.016, 1.024, and 1.016. Once I saw that he was able to concentrate his urine to some degree, I thought diabetes insipidus was ruled out. I suggested that the owner start to gradually limit his water intake, getting him down to an appropriate volume over about a week. I'm not sure if she ever did this. I also recommended a full chemistry.
Yesterday Duke came in for blood work because he has been loosing weight. He is now down to 69 lb and his BCS is 2/5. His owner said he has not been eating well, seems lethargic, and still is drinking a ton if allowed. Blood work:
TP 6.2 (5-7.4)
alb 3.6 (2.7-4.4)
ALT 38 (12-118)
ALP 111 (5-131)
GGTP 11 (1-12)
total bili 0.2 (0.1-0.3)
BUN 19 (4-27)
creat 1.0 (0.5-1.6)
phos 4.4 (2.5-6)
glucose 98 (70-1380
Ca 9.9 (8.9-11.4)
Na 161 (139-154) ***
K 5.0 (3.6-5.5)
Cl 122 (102-120) ***
A CBC was also done and was normal. So based on the elevated Na with extreme PU/PD and weight loss, all signs seem to be pointing towards diabetes insipidus. What is confusing me is that he was able to concentrate his urine when it was checked a few months ago. Does this fit with partial diabetes insipidus?
Thanks for your help. | Did you get a usg with most recent labs? | Now the question is why? |
Benson is a 5 year old, MN, 23-lb miniature schnauzer that was diagnosed with diabetes last month. Rest of bloodwork normal except elevated triglycerides (844).
Owner has been giving NPH insulin since diagnosis, starting at 6 units BID and then for some reason an associate bumped it up to 10 units BID. Spoke wtih owner and she appears to be giving insulin correctly. Based on urosticks showing tons of glucose at home (no ketones), owner increased to 11 units BID 4 days ago. Pet eats well as long as owner puts chicken on the food, but is pu/pd. We did a curve today. The only thing I'm worried about is owner usually gives food and insulin at 6:00 am, but we told her we'd ideally like to check the glucose before the insulin dose.
9:00 BG 415
9:15 Force fed normal food with a little a/d, insulin given: 11 units SQ
11:00 BG 336
1:30 BG 255
3:00 BG 295
5:00 BG 313
I know it would be ideal to get more readings but based on this curve I'm assuming I can safely increase the glucose to at least 12 units BID. That just seems like a high dose of insulin. Can we then just keep an eye on the urosticks to determine what the glucose is doing? When should we consider another curve?
I actually feel good about this patient but my confidence when it comes to diabetes is lacking because it just seems so complicated. Just wondering how the experts would feel about this curve. Thanks!! | What diet is he on? | How much and how frequently? |
12 y.o. FS DSH
18 months ago 12.5#
1 year ago 10.75#
8 mos ago 9# in for wellness care - ask owner about wt loss and she says they have been trying to decrease weight and she declined labs other than fecal which was NPS
now 6.1#
Owner now says they don't remember trying to get cat to lose weight. Ravenously hungry - attacks food, tries to steal human food which she had never done before.
No vomiting or arrhea. Other than acting odd (vocalizing and more sociable than previous) she acts like she feels fine.
Owner unsure on water consumption. Owner unsure if alopecia on back and tail is from grooming but they think so.
Wormed with OTC pyrantel a month ago. Drop off fecal sample NPS 2 weeks ago.
Physical exam normal other than alopecia over dorsum and tail and wt. loss. Mild plaque of molars but gums seem fine.
Thinking hyperthyroid or abetes
CBC - WBC# = 20640 (temp = 101.4)
Hct = 32
Comp Chem - WNL except amylase = 1189 (300-1100)
T4 = 2.7 (1.5-4.8)
Owner concerned with costs of further testing "if we weren't going to find anything" so I promised him to get a second opinion as to what some adtional rule outs may be.
I was really thinking hyperthyroism and have never doubted our vetscan numbers before but?
Neoplasia? Nothing on palpation or exam and normally wouldn't still be eating so vigorously.
EPI? Not too common in the feline world I thought
Malabsorption process I am not considering? Lymphoma? | Is the "ravenously hungry" cat actually eating? | Sure the owner doesn't give him any nsaids? |
12 y.o. FS DSH
18 months ago 12.5#
1 year ago 10.75#
8 mos ago 9# in for wellness care - ask owner about wt loss and she says they have been trying to decrease weight and she declined labs other than fecal which was NPS
now 6.1#
Owner now says they don't remember trying to get cat to lose weight. Ravenously hungry - attacks food, tries to steal human food which she had never done before.
No vomiting or arrhea. Other than acting odd (vocalizing and more sociable than previous) she acts like she feels fine.
Owner unsure on water consumption. Owner unsure if alopecia on back and tail is from grooming but they think so.
Wormed with OTC pyrantel a month ago. Drop off fecal sample NPS 2 weeks ago.
Physical exam normal other than alopecia over dorsum and tail and wt. loss. Mild plaque of molars but gums seem fine.
Thinking hyperthyroid or abetes
CBC - WBC# = 20640 (temp = 101.4)
Hct = 32
Comp Chem - WNL except amylase = 1189 (300-1100)
T4 = 2.7 (1.5-4.8)
Owner concerned with costs of further testing "if we weren't going to find anything" so I promised him to get a second opinion as to what some adtional rule outs may be.
I was really thinking hyperthyroism and have never doubted our vetscan numbers before but?
Neoplasia? Nothing on palpation or exam and normally wouldn't still be eating so vigorously.
EPI? Not too common in the feline world I thought
Malabsorption process I am not considering? Lymphoma? | What kind of food is being fed? | What treatment? |
12 y.o. FS DSH
18 months ago 12.5#
1 year ago 10.75#
8 mos ago 9# in for wellness care - ask owner about wt loss and she says they have been trying to decrease weight and she declined labs other than fecal which was NPS
now 6.1#
Owner now says they don't remember trying to get cat to lose weight. Ravenously hungry - attacks food, tries to steal human food which she had never done before.
No vomiting or arrhea. Other than acting odd (vocalizing and more sociable than previous) she acts like she feels fine.
Owner unsure on water consumption. Owner unsure if alopecia on back and tail is from grooming but they think so.
Wormed with OTC pyrantel a month ago. Drop off fecal sample NPS 2 weeks ago.
Physical exam normal other than alopecia over dorsum and tail and wt. loss. Mild plaque of molars but gums seem fine.
Thinking hyperthyroid or abetes
CBC - WBC# = 20640 (temp = 101.4)
Hct = 32
Comp Chem - WNL except amylase = 1189 (300-1100)
T4 = 2.7 (1.5-4.8)
Owner concerned with costs of further testing "if we weren't going to find anything" so I promised him to get a second opinion as to what some adtional rule outs may be.
I was really thinking hyperthyroism and have never doubted our vetscan numbers before but?
Neoplasia? Nothing on palpation or exam and normally wouldn't still be eating so vigorously.
EPI? Not too common in the feline world I thought
Malabsorption process I am not considering? Lymphoma? | Is there competition for food? | Is this diet complete and balanced, and from a reputable manufacturer? |
12 y.o. FS DSH
18 months ago 12.5#
1 year ago 10.75#
8 mos ago 9# in for wellness care - ask owner about wt loss and she says they have been trying to decrease weight and she declined labs other than fecal which was NPS
now 6.1#
Owner now says they don't remember trying to get cat to lose weight. Ravenously hungry - attacks food, tries to steal human food which she had never done before.
No vomiting or arrhea. Other than acting odd (vocalizing and more sociable than previous) she acts like she feels fine.
Owner unsure on water consumption. Owner unsure if alopecia on back and tail is from grooming but they think so.
Wormed with OTC pyrantel a month ago. Drop off fecal sample NPS 2 weeks ago.
Physical exam normal other than alopecia over dorsum and tail and wt. loss. Mild plaque of molars but gums seem fine.
Thinking hyperthyroid or abetes
CBC - WBC# = 20640 (temp = 101.4)
Hct = 32
Comp Chem - WNL except amylase = 1189 (300-1100)
T4 = 2.7 (1.5-4.8)
Owner concerned with costs of further testing "if we weren't going to find anything" so I promised him to get a second opinion as to what some adtional rule outs may be.
I was really thinking hyperthyroism and have never doubted our vetscan numbers before but?
Neoplasia? Nothing on palpation or exam and normally wouldn't still be eating so vigorously.
EPI? Not too common in the feline world I thought
Malabsorption process I am not considering? Lymphoma? | Have the owners actually measured the cat's food consumption? | Are there one or more palpable thyroid nodules? |
12 y.o. FS DSH
18 months ago 12.5#
1 year ago 10.75#
8 mos ago 9# in for wellness care - ask owner about wt loss and she says they have been trying to decrease weight and she declined labs other than fecal which was NPS
now 6.1#
Owner now says they don't remember trying to get cat to lose weight. Ravenously hungry - attacks food, tries to steal human food which she had never done before.
No vomiting or arrhea. Other than acting odd (vocalizing and more sociable than previous) she acts like she feels fine.
Owner unsure on water consumption. Owner unsure if alopecia on back and tail is from grooming but they think so.
Wormed with OTC pyrantel a month ago. Drop off fecal sample NPS 2 weeks ago.
Physical exam normal other than alopecia over dorsum and tail and wt. loss. Mild plaque of molars but gums seem fine.
Thinking hyperthyroid or abetes
CBC - WBC# = 20640 (temp = 101.4)
Hct = 32
Comp Chem - WNL except amylase = 1189 (300-1100)
T4 = 2.7 (1.5-4.8)
Owner concerned with costs of further testing "if we weren't going to find anything" so I promised him to get a second opinion as to what some adtional rule outs may be.
I was really thinking hyperthyroism and have never doubted our vetscan numbers before but?
Neoplasia? Nothing on palpation or exam and normally wouldn't still be eating so vigorously.
EPI? Not too common in the feline world I thought
Malabsorption process I am not considering? Lymphoma? | If you are convinced that the cat is indeed polyphagic, the next question is why? | Does the client work at times that do not permit a 12-hour curve? |
11 yr old chihuahua M(c) dx with DM back in january of this year (2013)...18.4 lbs...
on royal canin LF diet (patient is much overweight)...
started on NPH insulin 5 units BID...
first curve a week later and none of the BGs got lower than 400...
increased to 6 units and 1 week later, a couple BGs in high 300s, but otherwise 400s...
made a bigger increase to 8 units and a week later, most BGs in the 300s now...
went to 10 units...a week later and got a nadir of 173 at +6 hours (from 335, down to 173, up to 264)
now that the insulin showed effectiveness, i was happy it was at least working, and the nadir not too bad...but thought i had some room to increase a bit more...
11 units was started and a week later the curve was pretty much the same as on 10 units...with nadir 186 at +6 hours...
given that our insulin dose was getting higher and higher, really searched for any resistance issues...performed a dental (teeth weren't that bad however) and of course we have checked for UTI and has been negative...
owners also described having some trouble getting the insulin in everyday the same, as the dog seemed to be not tolerating the experience of injections...
they ended up buying an auto injector of NPH insulin...
decided to stay at 11 units after the dental to see if the cleaning helped improve the BGs...
next curve 10 days later revealed worse curve than previously on 11 units...this time, nadir 256 (from 400 to 256 to 320)...
given this curve, and the last 11 units curve with nadir of 186, i still thought i had room to go up...
12 units was started...and a week later...today:
BG +1 = 138
BG +3 = 103
BG +5 = 246
BG +7 = 281
SOOOO, the insulin is effective...the nadir is perfect (103 - could be lower...did not check +4), but the DOA is not very encouraging...the owner has said that lately they really think they have been doing it better (giving the insulin)...
the owner brought in urine strip from this AM, and it was negative for glucose...
could we be overdosing? and the BG is going up too soon here because it did drop too low and we are somogyi?
i know the right call is not to increase the dose, as i can't push my nadir much lower to feel safe...
i am just not sure if we should try a lower dose (now that owner feels like she is really getting it in) like 10 or 11 units again (when the nadir was not as good as 103 but it at least occured at +6 and the DOA was better) - the best curve was on 10 units (335 - 195 - 173 - 229 - 264) but i increased it thinking i could improve it at least somewhat more...)
OR
change insulin to a longer acting insulin?...the best this NPH has lasted (until BG >250) is about 9-10 hours (when on 10 units) which is fine with me, but this higher dose of 12 units is only revealing 4-5 hour DOA...
OR
keep everything the same and recheck another curve in a week or so (perhaps just daily variation?)...
i am thinking of lowering the dose to 10 units and re-evaluating...what do you think is best move here? (with the negative AM urine glucose, the BG of 139 only 1 hour after feed/insulin, and the better curve on 10 units, thought this was the safe move)...
thanks all... kane, dvm | New insulin...? | I.e. if you took away the fact that the dog has colored urine, is there anything else abnormal with how the dog voids urine? |
11 yr old chihuahua M(c) dx with DM back in january of this year (2013)...18.4 lbs...
on royal canin LF diet (patient is much overweight)...
started on NPH insulin 5 units BID...
first curve a week later and none of the BGs got lower than 400...
increased to 6 units and 1 week later, a couple BGs in high 300s, but otherwise 400s...
made a bigger increase to 8 units and a week later, most BGs in the 300s now...
went to 10 units...a week later and got a nadir of 173 at +6 hours (from 335, down to 173, up to 264)
now that the insulin showed effectiveness, i was happy it was at least working, and the nadir not too bad...but thought i had some room to increase a bit more...
11 units was started and a week later the curve was pretty much the same as on 10 units...with nadir 186 at +6 hours...
given that our insulin dose was getting higher and higher, really searched for any resistance issues...performed a dental (teeth weren't that bad however) and of course we have checked for UTI and has been negative...
owners also described having some trouble getting the insulin in everyday the same, as the dog seemed to be not tolerating the experience of injections...
they ended up buying an auto injector of NPH insulin...
decided to stay at 11 units after the dental to see if the cleaning helped improve the BGs...
next curve 10 days later revealed worse curve than previously on 11 units...this time, nadir 256 (from 400 to 256 to 320)...
given this curve, and the last 11 units curve with nadir of 186, i still thought i had room to go up...
12 units was started...and a week later...today:
BG +1 = 138
BG +3 = 103
BG +5 = 246
BG +7 = 281
SOOOO, the insulin is effective...the nadir is perfect (103 - could be lower...did not check +4), but the DOA is not very encouraging...the owner has said that lately they really think they have been doing it better (giving the insulin)...
the owner brought in urine strip from this AM, and it was negative for glucose...
could we be overdosing? and the BG is going up too soon here because it did drop too low and we are somogyi?
i know the right call is not to increase the dose, as i can't push my nadir much lower to feel safe...
i am just not sure if we should try a lower dose (now that owner feels like she is really getting it in) like 10 or 11 units again (when the nadir was not as good as 103 but it at least occured at +6 and the DOA was better) - the best curve was on 10 units (335 - 195 - 173 - 229 - 264) but i increased it thinking i could improve it at least somewhat more...)
OR
change insulin to a longer acting insulin?...the best this NPH has lasted (until BG >250) is about 9-10 hours (when on 10 units) which is fine with me, but this higher dose of 12 units is only revealing 4-5 hour DOA...
OR
keep everything the same and recheck another curve in a week or so (perhaps just daily variation?)...
i am thinking of lowering the dose to 10 units and re-evaluating...what do you think is best move here? (with the negative AM urine glucose, the BG of 139 only 1 hour after feed/insulin, and the better curve on 10 units, thought this was the safe move)...
thanks all... kane, dvm | Stay at same dose and recheck? | Wet? |
11 yr old chihuahua M(c) dx with DM back in january of this year (2013)...18.4 lbs...
on royal canin LF diet (patient is much overweight)...
started on NPH insulin 5 units BID...
first curve a week later and none of the BGs got lower than 400...
increased to 6 units and 1 week later, a couple BGs in high 300s, but otherwise 400s...
made a bigger increase to 8 units and a week later, most BGs in the 300s now...
went to 10 units...a week later and got a nadir of 173 at +6 hours (from 335, down to 173, up to 264)
now that the insulin showed effectiveness, i was happy it was at least working, and the nadir not too bad...but thought i had some room to increase a bit more...
11 units was started and a week later the curve was pretty much the same as on 10 units...with nadir 186 at +6 hours...
given that our insulin dose was getting higher and higher, really searched for any resistance issues...performed a dental (teeth weren't that bad however) and of course we have checked for UTI and has been negative...
owners also described having some trouble getting the insulin in everyday the same, as the dog seemed to be not tolerating the experience of injections...
they ended up buying an auto injector of NPH insulin...
decided to stay at 11 units after the dental to see if the cleaning helped improve the BGs...
next curve 10 days later revealed worse curve than previously on 11 units...this time, nadir 256 (from 400 to 256 to 320)...
given this curve, and the last 11 units curve with nadir of 186, i still thought i had room to go up...
12 units was started...and a week later...today:
BG +1 = 138
BG +3 = 103
BG +5 = 246
BG +7 = 281
SOOOO, the insulin is effective...the nadir is perfect (103 - could be lower...did not check +4), but the DOA is not very encouraging...the owner has said that lately they really think they have been doing it better (giving the insulin)...
the owner brought in urine strip from this AM, and it was negative for glucose...
could we be overdosing? and the BG is going up too soon here because it did drop too low and we are somogyi?
i know the right call is not to increase the dose, as i can't push my nadir much lower to feel safe...
i am just not sure if we should try a lower dose (now that owner feels like she is really getting it in) like 10 or 11 units again (when the nadir was not as good as 103 but it at least occured at +6 and the DOA was better) - the best curve was on 10 units (335 - 195 - 173 - 229 - 264) but i increased it thinking i could improve it at least somewhat more...)
OR
change insulin to a longer acting insulin?...the best this NPH has lasted (until BG >250) is about 9-10 hours (when on 10 units) which is fine with me, but this higher dose of 12 units is only revealing 4-5 hour DOA...
OR
keep everything the same and recheck another curve in a week or so (perhaps just daily variation?)...
i am thinking of lowering the dose to 10 units and re-evaluating...what do you think is best move here? (with the negative AM urine glucose, the BG of 139 only 1 hour after feed/insulin, and the better curve on 10 units, thought this was the safe move)...
thanks all... kane, dvm | Lower dose? | Is there hypercalcemia? |
I have a 6 year old MN, DSH diabetic. He was diagnosed about a year ago and initially was treated with glargine. The vet that started himm on that has had good success treating diabetic cats with glargine. He did not respond well to that medication - meaning his sugars did not come down. We then started him on Lantus. He continued to be pu/pd even on 6 units BID. Eventually switched to PZI. We are at 4 units BID, still pu/pd. Owner checks blood sugars at home and they have been in either the upper 200s or 300s. She is getting frustrated because his sugars are not any better on the insulin than they were when he was diagnosed. But if she stops the insulin his sugars go up to 500s. Urine culture has been negative, blood chesmistry, other than elevated glucose has been pretty normal. Are there some cats that just don't respond and are not well controlled no matter what? He is eating a low carb canned food. What else should I be thinking about? | Which glucometer does the owner have? | How many calories/day does he currently get? |
I have a 6 year old MN, DSH diabetic. He was diagnosed about a year ago and initially was treated with glargine. The vet that started himm on that has had good success treating diabetic cats with glargine. He did not respond well to that medication - meaning his sugars did not come down. We then started him on Lantus. He continued to be pu/pd even on 6 units BID. Eventually switched to PZI. We are at 4 units BID, still pu/pd. Owner checks blood sugars at home and they have been in either the upper 200s or 300s. She is getting frustrated because his sugars are not any better on the insulin than they were when he was diagnosed. But if she stops the insulin his sugars go up to 500s. Urine culture has been negative, blood chesmistry, other than elevated glucose has been pretty normal. Are there some cats that just don't respond and are not well controlled no matter what? He is eating a low carb canned food. What else should I be thinking about? | The owner isn't measuring single bg's, right? | Can the owner accurately measure and then inject the insulin successfully each time? |
I have a 6 year old MN, DSH diabetic. He was diagnosed about a year ago and initially was treated with glargine. The vet that started himm on that has had good success treating diabetic cats with glargine. He did not respond well to that medication - meaning his sugars did not come down. We then started him on Lantus. He continued to be pu/pd even on 6 units BID. Eventually switched to PZI. We are at 4 units BID, still pu/pd. Owner checks blood sugars at home and they have been in either the upper 200s or 300s. She is getting frustrated because his sugars are not any better on the insulin than they were when he was diagnosed. But if she stops the insulin his sugars go up to 500s. Urine culture has been negative, blood chesmistry, other than elevated glucose has been pretty normal. Are there some cats that just don't respond and are not well controlled no matter what? He is eating a low carb canned food. What else should I be thinking about? | Can i see a couple of the curves on the pzi? | How much should she weigh? |
I have a 6 year old MN, DSH diabetic. He was diagnosed about a year ago and initially was treated with glargine. The vet that started himm on that has had good success treating diabetic cats with glargine. He did not respond well to that medication - meaning his sugars did not come down. We then started him on Lantus. He continued to be pu/pd even on 6 units BID. Eventually switched to PZI. We are at 4 units BID, still pu/pd. Owner checks blood sugars at home and they have been in either the upper 200s or 300s. She is getting frustrated because his sugars are not any better on the insulin than they were when he was diagnosed. But if she stops the insulin his sugars go up to 500s. Urine culture has been negative, blood chesmistry, other than elevated glucose has been pretty normal. Are there some cats that just don't respond and are not well controlled no matter what? He is eating a low carb canned food. What else should I be thinking about? | A diabetic cat can be fed throughout the day, but the total amount has to be measured and should be reasonable for a cat this size? | Is the owner moving the injections around on the dog's body every day? |
I have a 6 year old MN, DSH diabetic. He was diagnosed about a year ago and initially was treated with glargine. The vet that started himm on that has had good success treating diabetic cats with glargine. He did not respond well to that medication - meaning his sugars did not come down. We then started him on Lantus. He continued to be pu/pd even on 6 units BID. Eventually switched to PZI. We are at 4 units BID, still pu/pd. Owner checks blood sugars at home and they have been in either the upper 200s or 300s. She is getting frustrated because his sugars are not any better on the insulin than they were when he was diagnosed. But if she stops the insulin his sugars go up to 500s. Urine culture has been negative, blood chesmistry, other than elevated glucose has been pretty normal. Are there some cats that just don't respond and are not well controlled no matter what? He is eating a low carb canned food. What else should I be thinking about? | Which canned food is the cat on? | Yes - i would send out for ultrasound - suspect renal dysplasia? |
I have a 6 year old MN, DSH diabetic. He was diagnosed about a year ago and initially was treated with glargine. The vet that started himm on that has had good success treating diabetic cats with glargine. He did not respond well to that medication - meaning his sugars did not come down. We then started him on Lantus. He continued to be pu/pd even on 6 units BID. Eventually switched to PZI. We are at 4 units BID, still pu/pd. Owner checks blood sugars at home and they have been in either the upper 200s or 300s. She is getting frustrated because his sugars are not any better on the insulin than they were when he was diagnosed. But if she stops the insulin his sugars go up to 500s. Urine culture has been negative, blood chesmistry, other than elevated glucose has been pretty normal. Are there some cats that just don't respond and are not well controlled no matter what? He is eating a low carb canned food. What else should I be thinking about? | Is he losing weight? | Hmmm...this owner sounds challenging : / free-choice feeding for a cat that has gained 7 pounds in the past year and she doesn't want to talk about it? |
I have a 6 year old MN, DSH diabetic. He was diagnosed about a year ago and initially was treated with glargine. The vet that started himm on that has had good success treating diabetic cats with glargine. He did not respond well to that medication - meaning his sugars did not come down. We then started him on Lantus. He continued to be pu/pd even on 6 units BID. Eventually switched to PZI. We are at 4 units BID, still pu/pd. Owner checks blood sugars at home and they have been in either the upper 200s or 300s. She is getting frustrated because his sugars are not any better on the insulin than they were when he was diagnosed. But if she stops the insulin his sugars go up to 500s. Urine culture has been negative, blood chesmistry, other than elevated glucose has been pretty normal. Are there some cats that just don't respond and are not well controlled no matter what? He is eating a low carb canned food. What else should I be thinking about? | Gaining weight? | Have you tried oral cerenia to prevent/stop this? |
Having trouble with an 18 y/o MN cat that has been a diabetic for 5-6 years, been well regulated, O is able to do blood glucose at home. He is on Lantus 4U BID. Has lost his appetite in last few weeks, came in for glucose curve last week and first 3 were 45-50mg/dl, then at 2 pm went up to 263 mg/dl, insulin given at 7A.
So at home his insulins have been in the 500s in AM before insulin but then 40s at 2pm.
He is eating high protein canned food but not Rx food.
Any suggestions for what I how I should progress? I fortunately dont have to deal with diabetics very often.
Thank you, | Were there any new findings on his physical exam? | How is the cat doing at home? |
Abbey is a 10 yr intact female toy poodle. DKA (pancreatitis) and diabetes diagnosis 2 months ago. Stablized after hospitalization for several days. We discussed at the time that she will need to be spayed or we won't be able to stablize the diabetes.
She has comedones, pot belly, thin hair coat and muscle wasting. Suspicious for Cushings but too many other complicating factors, wanted to try and get her stable and spayed before trying to stim her.
She has done well for a few months, we curved her and she has been on 5 units BID with food and doing well, less PU/PD, has lost some weight etc, more energetic etc. Then this week she seems lethargic again, eating well, actually ravenously, keeping owner up at night wanting more food. Owner changed the food at some point over the last 2 months without letting us know so that is also complicating things for me.
We admitted her yesterday morning, she had already had her insulin and food, was QAR, no significant dehydration. She has lost 1 lb since she was first diagnosed. Her comedones are more widespread and severe than ever.
She was mildly ketonuric 15 mg/dl yesterday with mild glucosuria but still eating.
Her readings throughout the day were as follows:
Insulin at 8 am
10am glucose 205 mg/dl
12pm 182 mg/dl
2pm 306 mg/dl
4pm 416 mg/dl
Since she is still eating and ketones were mild I sent her home for the night, advised them to feed her 25% more that night. Continue that amount in the morning and give 5.5units in the morning. At drop off this morning owner said she felt like she had an episode of extreme lethargy last night, so she gave her a pupperoni to get some sugar into her, thinking it was low glucose.
We discussed spaying her, possibly tomorrow, but today her ketonuria is higher 40mg/dl and glucosuria 1000mg/dl
CBC has a mild lymphopenia
Chem only abnormalities:
ALP 416 U/L (20-150)
Glucose 270 mg/dl
Other values WNL:
Bun is border line at 24 mg/dl (7-25)
Ca is borderline at 11.7mg/dl (8.6-11.8)
Creat 0.3 mg/dl (0.3-1.4)
K 4.5 mmol/l (3.7-5.8)
ALT 42 U/L (10-118)
Phos 5.6 mg/dl (2.9-6.6)
Alb 3.9 g/dl (2.5-4.4)
Na 149 mmol/l (138-160)
I started fluids on her
LRS 16mEqKCl/liter to see what that will do for us. Will recheck the urine dipstick later in the day to see.
The curve looked good to me, so I don't really know where the ketones are coming from, maybe owner has not been feeding enough? Maybe its because she is intact, or because she has Cushings?
Help
IDK whether to proceed with spay tomorrow as long as she stays BAR,and just feed dinner early and skip breakfast and insulin tomorrow? Then keep her on fluids during spay and then use regular insulin the rest of the day to clear ketones?
I am just very unsure of what to do next, any help greatly appreciated.
Thank you! | This is really a good time to teach the owner how to generate curves at home---any chance of that? | I take it his normal dose is 8 units bid before this latest problem? |
Abbey is a 10 yr intact female toy poodle. DKA (pancreatitis) and diabetes diagnosis 2 months ago. Stablized after hospitalization for several days. We discussed at the time that she will need to be spayed or we won't be able to stablize the diabetes.
She has comedones, pot belly, thin hair coat and muscle wasting. Suspicious for Cushings but too many other complicating factors, wanted to try and get her stable and spayed before trying to stim her.
She has done well for a few months, we curved her and she has been on 5 units BID with food and doing well, less PU/PD, has lost some weight etc, more energetic etc. Then this week she seems lethargic again, eating well, actually ravenously, keeping owner up at night wanting more food. Owner changed the food at some point over the last 2 months without letting us know so that is also complicating things for me.
We admitted her yesterday morning, she had already had her insulin and food, was QAR, no significant dehydration. She has lost 1 lb since she was first diagnosed. Her comedones are more widespread and severe than ever.
She was mildly ketonuric 15 mg/dl yesterday with mild glucosuria but still eating.
Her readings throughout the day were as follows:
Insulin at 8 am
10am glucose 205 mg/dl
12pm 182 mg/dl
2pm 306 mg/dl
4pm 416 mg/dl
Since she is still eating and ketones were mild I sent her home for the night, advised them to feed her 25% more that night. Continue that amount in the morning and give 5.5units in the morning. At drop off this morning owner said she felt like she had an episode of extreme lethargy last night, so she gave her a pupperoni to get some sugar into her, thinking it was low glucose.
We discussed spaying her, possibly tomorrow, but today her ketonuria is higher 40mg/dl and glucosuria 1000mg/dl
CBC has a mild lymphopenia
Chem only abnormalities:
ALP 416 U/L (20-150)
Glucose 270 mg/dl
Other values WNL:
Bun is border line at 24 mg/dl (7-25)
Ca is borderline at 11.7mg/dl (8.6-11.8)
Creat 0.3 mg/dl (0.3-1.4)
K 4.5 mmol/l (3.7-5.8)
ALT 42 U/L (10-118)
Phos 5.6 mg/dl (2.9-6.6)
Alb 3.9 g/dl (2.5-4.4)
Na 149 mmol/l (138-160)
I started fluids on her
LRS 16mEqKCl/liter to see what that will do for us. Will recheck the urine dipstick later in the day to see.
The curve looked good to me, so I don't really know where the ketones are coming from, maybe owner has not been feeding enough? Maybe its because she is intact, or because she has Cushings?
Help
IDK whether to proceed with spay tomorrow as long as she stays BAR,and just feed dinner early and skip breakfast and insulin tomorrow? Then keep her on fluids during spay and then use regular insulin the rest of the day to clear ketones?
I am just very unsure of what to do next, any help greatly appreciated.
Thank you! | How much does she weigh? | Could she have have cerebrovascular disease? |
10 F/S 15 # Schnauzer diagnosed with hyperadrenocorticism 3 years ago (PUPD, UTI, elevated liver enzymes) based on exaggerated ACTH stim (we do use a compounded product that has worked well when compared to cotrysin when we've compared it several years ago). At that time owner declined doing testing to differentiate adrenal vs pituitary and elected to treat with mitotane; used 250 mg daily for 5 days then had good control and has been maintained on 125 mg twice weekly since then. In Sept 2010 did have a UTI, found mass in cranioventral bladder which was surgically removed; histopath showed it to be hyperplastic polyp.
In May 2012 (most recent ACTH stim), pre level 3.6 and 2 hr post was 8.2.... a bit higher (I usually try to keep those levels fairly non stimulative) but we did not change the dose.
Presented for urinary incontinence in March; UA and culture showed UTI/isosthenuria obtained by Usd guided cysto which also revealed another polyp like lesion in cranial bladder. We have not done anything further diagnostically with that; the plan was to monitor it suspected that it most likely is another hyperplastic lesion in response to the infection. The whole abdomen (I.e. adrenals) were not evaluated. This is being treated with antibiotics for 6 weeks but we did confirm a negative culture after 10 days. At the same time as the initial UA, profile showed GGT 150, ALP 2551, ALT 210, chol, 336. Other parameters including electrolytes and CBC unremarkable except mild elevation in globulin.
Pre ACTH 7.7; post 16.4.
Increased mitotane to 125 mg q24h for 5 d.
Pre-ACTH was 4.8; post 14
Increased mitotane to 250 mg q24h for 5d
Pre-ACTH 7.1; post 14.8
Clinical signs have resolved.
My questions/concerns:
1. Should we continue the mitotane re-induction for a longer time and if so, how long before rechecking again and at what dose (of course the owner says "This is getting awfully expensive and the dog is just fine"
2. Should we switch to trilostane and if so, do you start at the normal dose & schedule given the fact that the dog has been on mitotane
3. Should we do something to evaluate the adrenals further (ultrasound, endogenous ACTH, other?)... and if his is the recommendation and the owner doesn't want to do this, what would plan "B" be?
4. Is there anything else you think I'm missing?
Thanks! | For a dog having lots of uti's i'd use the trilostane bid (e.g. start with 1 mg/kg bid).....are you pretty familiar with using it? | So i am thinking try to make returning to apartment low key, do some obedience commands as he enters building to keep his 'mind' and institute the calm command or stuffed kong to settle once in apartment? |
Hello, I am treating a 5 y/o FS english mastiff that has idiopathic head tremors. Screening blood tests have been completely normal with normal blood glucose levels. The owner read somewhere that idiopathic head tremors may be related to hypoglycemia so we ran fructosamine levels on two diferent occasions and the levels were a little low each time. The first fructosamine was 254 ( 260-378). The second was 247. What do you make of that? | Sounds like you've looked at bg's after a 12 hour fast? | Do we know how much weight willy has lost? |
Have a 16 yo Siamese MN with chronic al disease, diabetes and high normal thyroid tests. Appetite has decreased somewhat in the past few months and has lost about 1 lb. since Jan. Weighs 10.8. Used to weigh 1-2 years ago about 12.4. Cat eats ProPlan mixed with a little w/d and owner has started feeding Fancy Feast in the evening (has another Siamese cat - also diabetic and early al disease). They are eating less dry food since started feeding the Fancy Feast. Owner perceives cat is somewhat pupd (both cats).
We had gotten a low blood sugar on Harley (53) just on a routine checkup. She said that Harley wasn't as active as usual, but no overt signs of hypoglycemia. On 2 units Prozinc bid. We did a curve:
Fasting = 98
2hr = 90
4hr = 50 (gave a little Nutrical)
6hr = 78
8hr = 87
T4 at that time was 3.9 and fT4 was 44 (10-50).
Cat also had an arrythmia (HR of 100) that we did an EKG (Idexx) that was diagnosed as AV dissociation which could be secondary to metabolic disease or idiopathic. No treatment. Monitor HR.
We decided to stop insulin for a few days and see if cat really needed it or not.
After about 4 days, rechecked glucose = 319
Started back on ProZinc at 1 unit bid.
4/15/13: Recheck HR = 100 - no cardio symptoms
Glucose curve:
Fasting 153
2hr = 141
4hr = 129
6hr = 225
8hr = 205
Told owner to keep on 1 unit bid.
CBC = nomal except lymphopenia (228)
Profile: ALT =170 (10-100) - actually down a little; previously 249; BUN=81; Creat = 2.9 Amylase = 2826 (100-1200) Phos=5.4
T4=3.5; fT4=49 (10-50)
Urinalysis or BP not done recently.
Cat now weighs 10.8 lbs.
So, why is cat losing weight - this is my main concern right now? Underlying GIT disease? Progressing al disease? Cat is really hyperthyroid and levels could be normal due to sick euthyroid? I feel like the diabetes is stable.
Options? Do T3 suppression test? If hyperthyroid and decide to treat - could worsen al disease? Would cat have decreased appetite with hyperthyroidism?
Start al diet - if he likes it, might improve appetite and help al disease. Other cat might also benefit? SQ fluids once or twice a week and see if appetite improves?
Thanks,
Doug | Are the intestines thickened on exam? | Age? |
Diabetic cat presented for a glucose curve.
Recent 1 lb wt loss, PU/PD
Cat was fed at 7:45am ate a small amount and was given 5U Lantus
8:30am 398
10:30am 304
1:15pm 299
3:15 pm 244
5:15 pm 184
fructosamine = 471 poor control
Going to recommend increasing insulin to 5 1/2 U or 6U BID. Thoughts? | Anyone out there? | 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) how many calories/day does he currently get? |
Hi All,
I saw a case at a practice I occasionally locum for yesterday which has me, the permanent staff at the practice, and a referral practice all stumped. Any advice on the next move would be greatly appreciated!
The patient (Rosie) is a 2 year-old Female Neutered collie weighing 15kgs with a 3-4 month history of waxing and waning lethargy, vomiting and diarrhoea. Gastrointestinal biopsies have proved inconclusive, revealing changes consistent with gastroenteritis. An ACTH stimulation test was performed in February, with results within normal limits, and blood testing for ACh receptor antibodies was carried out to try to rule out myasthenia gravis - the result of this test was within normal limits too.
With no diagnosis forthcoming, the practice vets started Rosie on treatment with prednisolone 10mg BID, to which she seemed to respond quite well, though signs of lethargy returned when the dose was reduced by half. She was then started on methylprednisolone (6mg BID), about 10days prior to presenting to me yesterday.
Rosie presented to me yesterday morning with a 48hr history of lethargy and anorexia (she had not had any methylprednisolone for 48hrs due to the anorexia), 24hr history of vomiting, and diarrhoea which had started a few hours prior to presentation. She was very dull, though responsive, had pale mucous membranes and her heart rate varied between 52 and 76bpm. She seemed uncomfortable on abdominal palpation, adopting a hunched stance, but the abdomen was not tense and there was no evidence of pain at any specific site within the abdomen. Her temperature was 37.8C. I injected maropitant and dexadreson (4mg), and since she belonged to a member of staff, she stayed in the clinic for the day.
Rosie showed no signs of deterioration or improvement throughout the day. She remained dull but responsive but there was no further vomiting or diarrhoea. We offered a small amount of wet food (she is on waltham hypoallergenic diet) in the late afternoon and she vomited soon afterwards. I then administered IV fluids (500mls lactated ringers solution over 4 hours). She seemed a little brighter after the fluids and the owner took her home overnight. At home she became duller again and had some further diarrhoea.
Rosie presented at the clinic again this morning and has been put back on IV fluids (Sodium chloride). She seems brighter again and is now eating small amounts with no vomiting. I took some blood yesterday morning and the results came in this afternoon so I have posted them below. Notably, N:K ratio is normal.
I am struggling to account for Rosie's presentation. She could be have been hypovolaemic due to the vomiting and diarrhoea, which would account for her responding well to fluids but then why the bradycardia? At present she is being treated symptomatically and we are assuming some sort of inflammatory gastroenteritis but is there anything else we should be doing?
HAEMATOLOGY
Red Blood Cells 5.67 10^12/l 5.4-8.5
Haemoglobin 13.9 g/dl 12 - 18
Haematocrit/PCV 0.399 l/l 0.37-0.56
MCV 70.3 fl 65-75
MCH 24.5 pg
MCHC 34.8 g/dl 31- 35
WBC and Differential
White Blood Cells 6.4 10^9/l 5-18
Neutrophils 4.10 64% 10^9/l 3.7-13.32
Lymphocytes 1.47 23% 10^9/l 1.00-3.60
Monocytes 0.38 6% 10^9/l 0.20-0.72
Eosinophils 0.45 7% 10^9/l 0.10-1.25
Basophils 0.00 0% 10^9/l 0.05-0.18
Neutrophil:Lymphocyte ratio 2.78 :1
Undifferentiated cells 0.00 0% 10^9/l
Nucleated RBC * 1 /100 WBC 5
Platelet Count 261 10^9/l 200-500
Platelets appear adequate on smear.
Normochromic, normocytic RBCs. No WBC morphological changes. The WBC differential count was
checked manually
BIOCHEMISTRY
Alkaline Phosphatase 214 iu/l 7-173 (Adult)
ALT 23 iu/l 0-40
Gamma GT 4 iu/l 0-20
Total Protein 66 g/l 54-76
Albumin 32 g/l 25-39
Globulin 34 g/l 24-44
Albumin:Globulin Ratio 0.94 :1 0.50-1.20
Urea 8.8 mmol/l 3.5-7.0
Creatinine 70 umol/l 0-130
Total Calcium 2.68 mmol/l 2.2-3.0
Phosphorus 1.70 mmol/l 0.9-1.6
Cholesterol * 8.8 mmol/l 3.8-7.9
Glucose 4.9 mmol/l 3.0-5.5 Fastin
Chloride 112 mmol/l 95-117
Sodium 151 mmol/l 135-150
Potassium 3.5 mmol/l 3.5-5.6
Sodium Potassium Ratio 43 :1 >27:1 | How were the biopsies collected? | Does his bowel palpate as thickened? |
Hi All,
I saw a case at a practice I occasionally locum for yesterday which has me, the permanent staff at the practice, and a referral practice all stumped. Any advice on the next move would be greatly appreciated!
The patient (Rosie) is a 2 year-old Female Neutered collie weighing 15kgs with a 3-4 month history of waxing and waning lethargy, vomiting and diarrhoea. Gastrointestinal biopsies have proved inconclusive, revealing changes consistent with gastroenteritis. An ACTH stimulation test was performed in February, with results within normal limits, and blood testing for ACh receptor antibodies was carried out to try to rule out myasthenia gravis - the result of this test was within normal limits too.
With no diagnosis forthcoming, the practice vets started Rosie on treatment with prednisolone 10mg BID, to which she seemed to respond quite well, though signs of lethargy returned when the dose was reduced by half. She was then started on methylprednisolone (6mg BID), about 10days prior to presenting to me yesterday.
Rosie presented to me yesterday morning with a 48hr history of lethargy and anorexia (she had not had any methylprednisolone for 48hrs due to the anorexia), 24hr history of vomiting, and diarrhoea which had started a few hours prior to presentation. She was very dull, though responsive, had pale mucous membranes and her heart rate varied between 52 and 76bpm. She seemed uncomfortable on abdominal palpation, adopting a hunched stance, but the abdomen was not tense and there was no evidence of pain at any specific site within the abdomen. Her temperature was 37.8C. I injected maropitant and dexadreson (4mg), and since she belonged to a member of staff, she stayed in the clinic for the day.
Rosie showed no signs of deterioration or improvement throughout the day. She remained dull but responsive but there was no further vomiting or diarrhoea. We offered a small amount of wet food (she is on waltham hypoallergenic diet) in the late afternoon and she vomited soon afterwards. I then administered IV fluids (500mls lactated ringers solution over 4 hours). She seemed a little brighter after the fluids and the owner took her home overnight. At home she became duller again and had some further diarrhoea.
Rosie presented at the clinic again this morning and has been put back on IV fluids (Sodium chloride). She seems brighter again and is now eating small amounts with no vomiting. I took some blood yesterday morning and the results came in this afternoon so I have posted them below. Notably, N:K ratio is normal.
I am struggling to account for Rosie's presentation. She could be have been hypovolaemic due to the vomiting and diarrhoea, which would account for her responding well to fluids but then why the bradycardia? At present she is being treated symptomatically and we are assuming some sort of inflammatory gastroenteritis but is there anything else we should be doing?
HAEMATOLOGY
Red Blood Cells 5.67 10^12/l 5.4-8.5
Haemoglobin 13.9 g/dl 12 - 18
Haematocrit/PCV 0.399 l/l 0.37-0.56
MCV 70.3 fl 65-75
MCH 24.5 pg
MCHC 34.8 g/dl 31- 35
WBC and Differential
White Blood Cells 6.4 10^9/l 5-18
Neutrophils 4.10 64% 10^9/l 3.7-13.32
Lymphocytes 1.47 23% 10^9/l 1.00-3.60
Monocytes 0.38 6% 10^9/l 0.20-0.72
Eosinophils 0.45 7% 10^9/l 0.10-1.25
Basophils 0.00 0% 10^9/l 0.05-0.18
Neutrophil:Lymphocyte ratio 2.78 :1
Undifferentiated cells 0.00 0% 10^9/l
Nucleated RBC * 1 /100 WBC 5
Platelet Count 261 10^9/l 200-500
Platelets appear adequate on smear.
Normochromic, normocytic RBCs. No WBC morphological changes. The WBC differential count was
checked manually
BIOCHEMISTRY
Alkaline Phosphatase 214 iu/l 7-173 (Adult)
ALT 23 iu/l 0-40
Gamma GT 4 iu/l 0-20
Total Protein 66 g/l 54-76
Albumin 32 g/l 25-39
Globulin 34 g/l 24-44
Albumin:Globulin Ratio 0.94 :1 0.50-1.20
Urea 8.8 mmol/l 3.5-7.0
Creatinine 70 umol/l 0-130
Total Calcium 2.68 mmol/l 2.2-3.0
Phosphorus 1.70 mmol/l 0.9-1.6
Cholesterol * 8.8 mmol/l 3.8-7.9
Glucose 4.9 mmol/l 3.0-5.5 Fastin
Chloride 112 mmol/l 95-117
Sodium 151 mmol/l 135-150
Potassium 3.5 mmol/l 3.5-5.6
Sodium Potassium Ratio 43 :1 >27:1 | Can you post the biopsy results? | What should she weigh? |
Hi All,
I saw a case at a practice I occasionally locum for yesterday which has me, the permanent staff at the practice, and a referral practice all stumped. Any advice on the next move would be greatly appreciated!
The patient (Rosie) is a 2 year-old Female Neutered collie weighing 15kgs with a 3-4 month history of waxing and waning lethargy, vomiting and diarrhoea. Gastrointestinal biopsies have proved inconclusive, revealing changes consistent with gastroenteritis. An ACTH stimulation test was performed in February, with results within normal limits, and blood testing for ACh receptor antibodies was carried out to try to rule out myasthenia gravis - the result of this test was within normal limits too.
With no diagnosis forthcoming, the practice vets started Rosie on treatment with prednisolone 10mg BID, to which she seemed to respond quite well, though signs of lethargy returned when the dose was reduced by half. She was then started on methylprednisolone (6mg BID), about 10days prior to presenting to me yesterday.
Rosie presented to me yesterday morning with a 48hr history of lethargy and anorexia (she had not had any methylprednisolone for 48hrs due to the anorexia), 24hr history of vomiting, and diarrhoea which had started a few hours prior to presentation. She was very dull, though responsive, had pale mucous membranes and her heart rate varied between 52 and 76bpm. She seemed uncomfortable on abdominal palpation, adopting a hunched stance, but the abdomen was not tense and there was no evidence of pain at any specific site within the abdomen. Her temperature was 37.8C. I injected maropitant and dexadreson (4mg), and since she belonged to a member of staff, she stayed in the clinic for the day.
Rosie showed no signs of deterioration or improvement throughout the day. She remained dull but responsive but there was no further vomiting or diarrhoea. We offered a small amount of wet food (she is on waltham hypoallergenic diet) in the late afternoon and she vomited soon afterwards. I then administered IV fluids (500mls lactated ringers solution over 4 hours). She seemed a little brighter after the fluids and the owner took her home overnight. At home she became duller again and had some further diarrhoea.
Rosie presented at the clinic again this morning and has been put back on IV fluids (Sodium chloride). She seems brighter again and is now eating small amounts with no vomiting. I took some blood yesterday morning and the results came in this afternoon so I have posted them below. Notably, N:K ratio is normal.
I am struggling to account for Rosie's presentation. She could be have been hypovolaemic due to the vomiting and diarrhoea, which would account for her responding well to fluids but then why the bradycardia? At present she is being treated symptomatically and we are assuming some sort of inflammatory gastroenteritis but is there anything else we should be doing?
HAEMATOLOGY
Red Blood Cells 5.67 10^12/l 5.4-8.5
Haemoglobin 13.9 g/dl 12 - 18
Haematocrit/PCV 0.399 l/l 0.37-0.56
MCV 70.3 fl 65-75
MCH 24.5 pg
MCHC 34.8 g/dl 31- 35
WBC and Differential
White Blood Cells 6.4 10^9/l 5-18
Neutrophils 4.10 64% 10^9/l 3.7-13.32
Lymphocytes 1.47 23% 10^9/l 1.00-3.60
Monocytes 0.38 6% 10^9/l 0.20-0.72
Eosinophils 0.45 7% 10^9/l 0.10-1.25
Basophils 0.00 0% 10^9/l 0.05-0.18
Neutrophil:Lymphocyte ratio 2.78 :1
Undifferentiated cells 0.00 0% 10^9/l
Nucleated RBC * 1 /100 WBC 5
Platelet Count 261 10^9/l 200-500
Platelets appear adequate on smear.
Normochromic, normocytic RBCs. No WBC morphological changes. The WBC differential count was
checked manually
BIOCHEMISTRY
Alkaline Phosphatase 214 iu/l 7-173 (Adult)
ALT 23 iu/l 0-40
Gamma GT 4 iu/l 0-20
Total Protein 66 g/l 54-76
Albumin 32 g/l 25-39
Globulin 34 g/l 24-44
Albumin:Globulin Ratio 0.94 :1 0.50-1.20
Urea 8.8 mmol/l 3.5-7.0
Creatinine 70 umol/l 0-130
Total Calcium 2.68 mmol/l 2.2-3.0
Phosphorus 1.70 mmol/l 0.9-1.6
Cholesterol * 8.8 mmol/l 3.8-7.9
Glucose 4.9 mmol/l 3.0-5.5 Fastin
Chloride 112 mmol/l 95-117
Sodium 151 mmol/l 135-150
Potassium 3.5 mmol/l 3.5-5.6
Sodium Potassium Ratio 43 :1 >27:1 | Has the dog seen a specialist? | Has the owner's glucometer been checked for accuracy? |
Hi All,
I saw a case at a practice I occasionally locum for yesterday which has me, the permanent staff at the practice, and a referral practice all stumped. Any advice on the next move would be greatly appreciated!
The patient (Rosie) is a 2 year-old Female Neutered collie weighing 15kgs with a 3-4 month history of waxing and waning lethargy, vomiting and diarrhoea. Gastrointestinal biopsies have proved inconclusive, revealing changes consistent with gastroenteritis. An ACTH stimulation test was performed in February, with results within normal limits, and blood testing for ACh receptor antibodies was carried out to try to rule out myasthenia gravis - the result of this test was within normal limits too.
With no diagnosis forthcoming, the practice vets started Rosie on treatment with prednisolone 10mg BID, to which she seemed to respond quite well, though signs of lethargy returned when the dose was reduced by half. She was then started on methylprednisolone (6mg BID), about 10days prior to presenting to me yesterday.
Rosie presented to me yesterday morning with a 48hr history of lethargy and anorexia (she had not had any methylprednisolone for 48hrs due to the anorexia), 24hr history of vomiting, and diarrhoea which had started a few hours prior to presentation. She was very dull, though responsive, had pale mucous membranes and her heart rate varied between 52 and 76bpm. She seemed uncomfortable on abdominal palpation, adopting a hunched stance, but the abdomen was not tense and there was no evidence of pain at any specific site within the abdomen. Her temperature was 37.8C. I injected maropitant and dexadreson (4mg), and since she belonged to a member of staff, she stayed in the clinic for the day.
Rosie showed no signs of deterioration or improvement throughout the day. She remained dull but responsive but there was no further vomiting or diarrhoea. We offered a small amount of wet food (she is on waltham hypoallergenic diet) in the late afternoon and she vomited soon afterwards. I then administered IV fluids (500mls lactated ringers solution over 4 hours). She seemed a little brighter after the fluids and the owner took her home overnight. At home she became duller again and had some further diarrhoea.
Rosie presented at the clinic again this morning and has been put back on IV fluids (Sodium chloride). She seems brighter again and is now eating small amounts with no vomiting. I took some blood yesterday morning and the results came in this afternoon so I have posted them below. Notably, N:K ratio is normal.
I am struggling to account for Rosie's presentation. She could be have been hypovolaemic due to the vomiting and diarrhoea, which would account for her responding well to fluids but then why the bradycardia? At present she is being treated symptomatically and we are assuming some sort of inflammatory gastroenteritis but is there anything else we should be doing?
HAEMATOLOGY
Red Blood Cells 5.67 10^12/l 5.4-8.5
Haemoglobin 13.9 g/dl 12 - 18
Haematocrit/PCV 0.399 l/l 0.37-0.56
MCV 70.3 fl 65-75
MCH 24.5 pg
MCHC 34.8 g/dl 31- 35
WBC and Differential
White Blood Cells 6.4 10^9/l 5-18
Neutrophils 4.10 64% 10^9/l 3.7-13.32
Lymphocytes 1.47 23% 10^9/l 1.00-3.60
Monocytes 0.38 6% 10^9/l 0.20-0.72
Eosinophils 0.45 7% 10^9/l 0.10-1.25
Basophils 0.00 0% 10^9/l 0.05-0.18
Neutrophil:Lymphocyte ratio 2.78 :1
Undifferentiated cells 0.00 0% 10^9/l
Nucleated RBC * 1 /100 WBC 5
Platelet Count 261 10^9/l 200-500
Platelets appear adequate on smear.
Normochromic, normocytic RBCs. No WBC morphological changes. The WBC differential count was
checked manually
BIOCHEMISTRY
Alkaline Phosphatase 214 iu/l 7-173 (Adult)
ALT 23 iu/l 0-40
Gamma GT 4 iu/l 0-20
Total Protein 66 g/l 54-76
Albumin 32 g/l 25-39
Globulin 34 g/l 24-44
Albumin:Globulin Ratio 0.94 :1 0.50-1.20
Urea 8.8 mmol/l 3.5-7.0
Creatinine 70 umol/l 0-130
Total Calcium 2.68 mmol/l 2.2-3.0
Phosphorus 1.70 mmol/l 0.9-1.6
Cholesterol * 8.8 mmol/l 3.8-7.9
Glucose 4.9 mmol/l 3.0-5.5 Fastin
Chloride 112 mmol/l 95-117
Sodium 151 mmol/l 135-150
Potassium 3.5 mmol/l 3.5-5.6
Sodium Potassium Ratio 43 :1 >27:1 | Was the bradycardia responsive to atropine? | Certain that insulin is being administered properly? |
Hi All,
I saw a case at a practice I occasionally locum for yesterday which has me, the permanent staff at the practice, and a referral practice all stumped. Any advice on the next move would be greatly appreciated!
The patient (Rosie) is a 2 year-old Female Neutered collie weighing 15kgs with a 3-4 month history of waxing and waning lethargy, vomiting and diarrhoea. Gastrointestinal biopsies have proved inconclusive, revealing changes consistent with gastroenteritis. An ACTH stimulation test was performed in February, with results within normal limits, and blood testing for ACh receptor antibodies was carried out to try to rule out myasthenia gravis - the result of this test was within normal limits too.
With no diagnosis forthcoming, the practice vets started Rosie on treatment with prednisolone 10mg BID, to which she seemed to respond quite well, though signs of lethargy returned when the dose was reduced by half. She was then started on methylprednisolone (6mg BID), about 10days prior to presenting to me yesterday.
Rosie presented to me yesterday morning with a 48hr history of lethargy and anorexia (she had not had any methylprednisolone for 48hrs due to the anorexia), 24hr history of vomiting, and diarrhoea which had started a few hours prior to presentation. She was very dull, though responsive, had pale mucous membranes and her heart rate varied between 52 and 76bpm. She seemed uncomfortable on abdominal palpation, adopting a hunched stance, but the abdomen was not tense and there was no evidence of pain at any specific site within the abdomen. Her temperature was 37.8C. I injected maropitant and dexadreson (4mg), and since she belonged to a member of staff, she stayed in the clinic for the day.
Rosie showed no signs of deterioration or improvement throughout the day. She remained dull but responsive but there was no further vomiting or diarrhoea. We offered a small amount of wet food (she is on waltham hypoallergenic diet) in the late afternoon and she vomited soon afterwards. I then administered IV fluids (500mls lactated ringers solution over 4 hours). She seemed a little brighter after the fluids and the owner took her home overnight. At home she became duller again and had some further diarrhoea.
Rosie presented at the clinic again this morning and has been put back on IV fluids (Sodium chloride). She seems brighter again and is now eating small amounts with no vomiting. I took some blood yesterday morning and the results came in this afternoon so I have posted them below. Notably, N:K ratio is normal.
I am struggling to account for Rosie's presentation. She could be have been hypovolaemic due to the vomiting and diarrhoea, which would account for her responding well to fluids but then why the bradycardia? At present she is being treated symptomatically and we are assuming some sort of inflammatory gastroenteritis but is there anything else we should be doing?
HAEMATOLOGY
Red Blood Cells 5.67 10^12/l 5.4-8.5
Haemoglobin 13.9 g/dl 12 - 18
Haematocrit/PCV 0.399 l/l 0.37-0.56
MCV 70.3 fl 65-75
MCH 24.5 pg
MCHC 34.8 g/dl 31- 35
WBC and Differential
White Blood Cells 6.4 10^9/l 5-18
Neutrophils 4.10 64% 10^9/l 3.7-13.32
Lymphocytes 1.47 23% 10^9/l 1.00-3.60
Monocytes 0.38 6% 10^9/l 0.20-0.72
Eosinophils 0.45 7% 10^9/l 0.10-1.25
Basophils 0.00 0% 10^9/l 0.05-0.18
Neutrophil:Lymphocyte ratio 2.78 :1
Undifferentiated cells 0.00 0% 10^9/l
Nucleated RBC * 1 /100 WBC 5
Platelet Count 261 10^9/l 200-500
Platelets appear adequate on smear.
Normochromic, normocytic RBCs. No WBC morphological changes. The WBC differential count was
checked manually
BIOCHEMISTRY
Alkaline Phosphatase 214 iu/l 7-173 (Adult)
ALT 23 iu/l 0-40
Gamma GT 4 iu/l 0-20
Total Protein 66 g/l 54-76
Albumin 32 g/l 25-39
Globulin 34 g/l 24-44
Albumin:Globulin Ratio 0.94 :1 0.50-1.20
Urea 8.8 mmol/l 3.5-7.0
Creatinine 70 umol/l 0-130
Total Calcium 2.68 mmol/l 2.2-3.0
Phosphorus 1.70 mmol/l 0.9-1.6
Cholesterol * 8.8 mmol/l 3.8-7.9
Glucose 4.9 mmol/l 3.0-5.5 Fastin
Chloride 112 mmol/l 95-117
Sodium 151 mmol/l 135-150
Potassium 3.5 mmol/l 3.5-5.6
Sodium Potassium Ratio 43 :1 >27:1 | Fluids? | Would the client be able to check bg's at home? |
Moxie is an 8 year old DLH cat who presented with diarrhea of 4 days duration at the beginning of April. I'll go over this cat's extensive his first, then discuss the current problem. My colleague has been the only one to examine this cat except for the April visit when I saw it.
His: The owner obtained this cat from a shelter when it was a kitten in 2005. Indoor only cat. Was overweight in 2007, not seen after until 2009. Cat was in for an exam, vaccines and decreased appetite and weight loss. Vaccines not given and blood was drawn.
May 2009 bldwk: CBC- high normal HCT (14.2), eosinophilia (15%); GHP- ALT=202(up to 100), AST=97 (up to 55);normal alk phos; all else, including T4 was WNL. My Colleague put her on amoxicillin for 14 days.
June 2009: Reck. liver enzymes- all back to normal at that time.
Nov 2009: No exam done (?), but blood drawn for recheck GHP/CBC. Again had high ALT (248) and AST (104) Still normal ALK Phos. Eosinophils still increased (17%). No exam done, no notes on concerns of owner written. animal put on amoxicillin for 3 weeks.
Jan 2010: No exam. No notes. Looks like a fecal was sent out (assuming diarrhea the complaint?)
Cat was put on Orbax for 8 days (why?) NSF on the fecal
Mid Jan 2010: Hurray, some notes. STILL no exam. O says diarrhea not resolving.
Cat was put on Amoxicillin and Tylan powder. Slight improvement by end of Jan.
Mid Mar 2010: O says diarrhea has not stopped and she is ready to euthanize (remember, NO exams for 9 months now). STILL NO EXAM. Cat was put on Prednisolone for 2 week trial.
End Mar 2010: Moderate improvement on Pred. Pred refilled 2 more times cat on 5mg daily.
May 2010: Seen for WELLNESS! exam. at that time diarrhea was improved but not fully resolved.
No notes indicated for abnormalities. Apparently came up with IBD as the diagnosis. No notes on recommendations for an ultrasound, rads, etc.
May2011: Wellness exam. Cat apparently back to normal, with no diarrhea. Still on 5mg prednisolone daily. recommended taper to EOD, then continued to refill for daily 5mg dose
Sept 2012: Wellness. O still giving 5mg prednisolone daily. No notes on whether tried to taper or not. No diarrhea, But noted weight loss and thin, unkempt haircoat noted on the exam.
Continued to refill pred.
Seen once at ER for drooling, odd nauseous behavior. O declined bloodwork and cat was back to normal the next day. Apparently, from reading the ER report, the cat has been having occasional vomiting and diarrhea episodes which quickly resolve.
Current Problem:
I saw this cat and had the initial impression (until I really looked at the his) that this cat was an IBD cat (still could be...) and had been worked up to diagnose it.
The cat is being fed Purina naturals dry, Friskies canned and some k/d (her other cat has chronic renal failure). Eating k/d started around 9 months ago when the other cat started on it. That is the only diet change. Diarrhea was watery and owner noted occasional diarrhea that resolved on its own.
Her dog recently died suddenly at a young age, so some stress in house. Her behavior is a little off, but no weight loss with this recent bout (13#)-and that is an ok weight for her. My exam revealed a cat that was slightly uncomfortable to palpation of the cranial abdomen with normal hydration and no other significant finding. She had mild tartar and no palpable thyroid nodules.
Fecal sample was brown color, cowpie texture. ON the smear I saw mild, if any rod overgrowth (really NSF) Sent to the lab.
I put this cat on Metronidazole for 14 days, since I do that with all my pancreas/IBD sorts of cats (and because it is sooo fun for the owners to give :)
We discussed cobolamine injections. Note: besides the diarrhea, O thinks the cat is doing fine.
Had liquid diarrhea while on the metronidazole. I recommended increase the pred dose temporarily to 5mg BID (7 days). Fecal results: NSF for giardia and parasites
Bottom line is stools continue to bounce between semi formed to liquid regardless of what I give/do.
I talked to the owner about doing bloodwork and ultrasound. She has made it clear she put everything into her dog that died - ER/ Specialty clinic work up and will not be able to do much in the way of diagnostics. I bet I could talk her into bloodwork, but I don't know if the bloodwork will really help me if I am picking and choosing. Should I just have her save for an ultrasound instead? Should I do a general deworming since it doesn't look like anything was ever done (nsf fecals) and has had high eosinophil counts in past. I use 5 days of panacur in these cases for dogs... What would you use for this cat? The discomfort in cranial abdomen has me thinking triaditis in this cat, too. Would you start cobolamine? What would you do with the pred after this length of time on it?
Sorry so wordy, but I thought the his was pertinent. | How has the cat's weight been at the past few visits? | What was his serum phosphorus? |
I saw Tucker last week for a presenting complaint of wt. loss and voracious appetite.
We have not seen him since 2010 but he had been apparently healthy in the last 3 years. Have just moved to new house- 3 wks ago. Tucker seems to be settling well. O has notice wt. loss in last 2 months. Voracious appetite, will now jump up on counters looking for food. Thinks his drinking might have incsed. Difficult to comment on U as has 2 other cats. No V/D.
GPE-BAR has lost 1 kg since last weighed (2010 but O feels wt was consistent until 2 months ago). eyes and ears-NAF, teeth- M2 tartar and gingivitis. Possible thickened tissue in a of thyroid? chest-NAF, Abdo-soft, comfortable, bladder is empty, kidneys-smooth. intestinal loops are soft, no masses palpable. LN-WNL, coat- excellent. good hind limb muscling.
wt=3.8 kg
T=38.1C
HR=240, regular rhythm, no murmurs
RR=60bpm
CRT2
BCS=2.5/5
GGH but unexplained wt. loss and incsed appetite, poss incse in drinking? R/O hyperthyroidism, diabetes, kidney or liver failure, glomerulonephritis.
Bladder was empty so no U sample obtained, did take blood for full chemistry, T4 and CBC.
Suggested once Blood results back should return for U sample if no diagnosis from blood results.
All biochemistry blood results were normal! T4 was normal at 48.6 nmol/L.
CBC was essentially all normal, the only abn being a mild lymphopenia - Lymphocytes 1.2 (N=1.5-7.0 X 10E9/L)
Tucker returned for collection of a U sample: need to give him SQ fluids to get him to produce as no bladder palpable when admitted.
The U results are as follows:
sp. gravity= 1.050
all stick pads were negative except for protein at 2+
No sediment visible after sample was centrifuged. Sample sent off for UPCR
URINE PROTEIN 67 mg/dl
URINE CREATININE 24810 umol/L
URINE PROTEIN/CREATININE RATIO 0.2 (0.0 - 0.2)
We did a BP measurement while in clinic: we did 3 measurements that ranged 125-130
From all the tests I have ruled out: Hyperthyroidism, renal/hepatic dz, diabetes.
I wondered about poss. glomerulonephritis-- but with the UPCR at 0.2 it is in the borderline range.
There does not seem to be any evidence of neoplasia... but that possibility is lurking in the background for a cat with unexplained wt. loss!
I considered putting him on a low protein, low salt diet, but wondering if it is too early to even do this? Should I just suggest rechecking a UPCR in 2-4 months?
In the meantime I have suggested a good quality senior diet (Medical Senior consult) to ensure that he is getting appropriate calories.
Not sure anything else is indicated yet. Feel it may be too early to think about Benazepril.
I have warned the owners about possible neoplasia (intestinal?).
I did think about doing an FIV/FeLV test, but not sure how the answer would change my approach?
So I am just wondering where to go from here?
Any suggestions? Anything I have missed?
Appreciate your thoughts,
☼ | Could you post the full bloodwork just for interest sake? | The owners move the insulin around on his body every day? |
I saw Tucker last week for a presenting complaint of wt. loss and voracious appetite.
We have not seen him since 2010 but he had been apparently healthy in the last 3 years. Have just moved to new house- 3 wks ago. Tucker seems to be settling well. O has notice wt. loss in last 2 months. Voracious appetite, will now jump up on counters looking for food. Thinks his drinking might have incsed. Difficult to comment on U as has 2 other cats. No V/D.
GPE-BAR has lost 1 kg since last weighed (2010 but O feels wt was consistent until 2 months ago). eyes and ears-NAF, teeth- M2 tartar and gingivitis. Possible thickened tissue in a of thyroid? chest-NAF, Abdo-soft, comfortable, bladder is empty, kidneys-smooth. intestinal loops are soft, no masses palpable. LN-WNL, coat- excellent. good hind limb muscling.
wt=3.8 kg
T=38.1C
HR=240, regular rhythm, no murmurs
RR=60bpm
CRT2
BCS=2.5/5
GGH but unexplained wt. loss and incsed appetite, poss incse in drinking? R/O hyperthyroidism, diabetes, kidney or liver failure, glomerulonephritis.
Bladder was empty so no U sample obtained, did take blood for full chemistry, T4 and CBC.
Suggested once Blood results back should return for U sample if no diagnosis from blood results.
All biochemistry blood results were normal! T4 was normal at 48.6 nmol/L.
CBC was essentially all normal, the only abn being a mild lymphopenia - Lymphocytes 1.2 (N=1.5-7.0 X 10E9/L)
Tucker returned for collection of a U sample: need to give him SQ fluids to get him to produce as no bladder palpable when admitted.
The U results are as follows:
sp. gravity= 1.050
all stick pads were negative except for protein at 2+
No sediment visible after sample was centrifuged. Sample sent off for UPCR
URINE PROTEIN 67 mg/dl
URINE CREATININE 24810 umol/L
URINE PROTEIN/CREATININE RATIO 0.2 (0.0 - 0.2)
We did a BP measurement while in clinic: we did 3 measurements that ranged 125-130
From all the tests I have ruled out: Hyperthyroidism, renal/hepatic dz, diabetes.
I wondered about poss. glomerulonephritis-- but with the UPCR at 0.2 it is in the borderline range.
There does not seem to be any evidence of neoplasia... but that possibility is lurking in the background for a cat with unexplained wt. loss!
I considered putting him on a low protein, low salt diet, but wondering if it is too early to even do this? Should I just suggest rechecking a UPCR in 2-4 months?
In the meantime I have suggested a good quality senior diet (Medical Senior consult) to ensure that he is getting appropriate calories.
Not sure anything else is indicated yet. Feel it may be too early to think about Benazepril.
I have warned the owners about possible neoplasia (intestinal?).
I did think about doing an FIV/FeLV test, but not sure how the answer would change my approach?
So I am just wondering where to go from here?
Any suggestions? Anything I have missed?
Appreciate your thoughts,
☼ | What is the reference range for the t4? | The owner is only feeding at metimes, when the insulin is given, using a measuring cup and the amount is reasonable for a dog this size (sometimes when the weight is fling off of them they panic and start rely over-feeding the dog---which means we have to chase after them with an ever-increasing amount of insulin) how many cories does he currently get? |
I saw Tucker last week for a presenting complaint of wt. loss and voracious appetite.
We have not seen him since 2010 but he had been apparently healthy in the last 3 years. Have just moved to new house- 3 wks ago. Tucker seems to be settling well. O has notice wt. loss in last 2 months. Voracious appetite, will now jump up on counters looking for food. Thinks his drinking might have incsed. Difficult to comment on U as has 2 other cats. No V/D.
GPE-BAR has lost 1 kg since last weighed (2010 but O feels wt was consistent until 2 months ago). eyes and ears-NAF, teeth- M2 tartar and gingivitis. Possible thickened tissue in a of thyroid? chest-NAF, Abdo-soft, comfortable, bladder is empty, kidneys-smooth. intestinal loops are soft, no masses palpable. LN-WNL, coat- excellent. good hind limb muscling.
wt=3.8 kg
T=38.1C
HR=240, regular rhythm, no murmurs
RR=60bpm
CRT2
BCS=2.5/5
GGH but unexplained wt. loss and incsed appetite, poss incse in drinking? R/O hyperthyroidism, diabetes, kidney or liver failure, glomerulonephritis.
Bladder was empty so no U sample obtained, did take blood for full chemistry, T4 and CBC.
Suggested once Blood results back should return for U sample if no diagnosis from blood results.
All biochemistry blood results were normal! T4 was normal at 48.6 nmol/L.
CBC was essentially all normal, the only abn being a mild lymphopenia - Lymphocytes 1.2 (N=1.5-7.0 X 10E9/L)
Tucker returned for collection of a U sample: need to give him SQ fluids to get him to produce as no bladder palpable when admitted.
The U results are as follows:
sp. gravity= 1.050
all stick pads were negative except for protein at 2+
No sediment visible after sample was centrifuged. Sample sent off for UPCR
URINE PROTEIN 67 mg/dl
URINE CREATININE 24810 umol/L
URINE PROTEIN/CREATININE RATIO 0.2 (0.0 - 0.2)
We did a BP measurement while in clinic: we did 3 measurements that ranged 125-130
From all the tests I have ruled out: Hyperthyroidism, renal/hepatic dz, diabetes.
I wondered about poss. glomerulonephritis-- but with the UPCR at 0.2 it is in the borderline range.
There does not seem to be any evidence of neoplasia... but that possibility is lurking in the background for a cat with unexplained wt. loss!
I considered putting him on a low protein, low salt diet, but wondering if it is too early to even do this? Should I just suggest rechecking a UPCR in 2-4 months?
In the meantime I have suggested a good quality senior diet (Medical Senior consult) to ensure that he is getting appropriate calories.
Not sure anything else is indicated yet. Feel it may be too early to think about Benazepril.
I have warned the owners about possible neoplasia (intestinal?).
I did think about doing an FIV/FeLV test, but not sure how the answer would change my approach?
So I am just wondering where to go from here?
Any suggestions? Anything I have missed?
Appreciate your thoughts,
☼ | Maybe you caught the t4 at a low point? | What exactly is happening when they 'can't get a sample'? |
I saw Tucker last week for a presenting complaint of wt. loss and voracious appetite.
We have not seen him since 2010 but he had been apparently healthy in the last 3 years. Have just moved to new house- 3 wks ago. Tucker seems to be settling well. O has notice wt. loss in last 2 months. Voracious appetite, will now jump up on counters looking for food. Thinks his drinking might have incsed. Difficult to comment on U as has 2 other cats. No V/D.
GPE-BAR has lost 1 kg since last weighed (2010 but O feels wt was consistent until 2 months ago). eyes and ears-NAF, teeth- M2 tartar and gingivitis. Possible thickened tissue in a of thyroid? chest-NAF, Abdo-soft, comfortable, bladder is empty, kidneys-smooth. intestinal loops are soft, no masses palpable. LN-WNL, coat- excellent. good hind limb muscling.
wt=3.8 kg
T=38.1C
HR=240, regular rhythm, no murmurs
RR=60bpm
CRT2
BCS=2.5/5
GGH but unexplained wt. loss and incsed appetite, poss incse in drinking? R/O hyperthyroidism, diabetes, kidney or liver failure, glomerulonephritis.
Bladder was empty so no U sample obtained, did take blood for full chemistry, T4 and CBC.
Suggested once Blood results back should return for U sample if no diagnosis from blood results.
All biochemistry blood results were normal! T4 was normal at 48.6 nmol/L.
CBC was essentially all normal, the only abn being a mild lymphopenia - Lymphocytes 1.2 (N=1.5-7.0 X 10E9/L)
Tucker returned for collection of a U sample: need to give him SQ fluids to get him to produce as no bladder palpable when admitted.
The U results are as follows:
sp. gravity= 1.050
all stick pads were negative except for protein at 2+
No sediment visible after sample was centrifuged. Sample sent off for UPCR
URINE PROTEIN 67 mg/dl
URINE CREATININE 24810 umol/L
URINE PROTEIN/CREATININE RATIO 0.2 (0.0 - 0.2)
We did a BP measurement while in clinic: we did 3 measurements that ranged 125-130
From all the tests I have ruled out: Hyperthyroidism, renal/hepatic dz, diabetes.
I wondered about poss. glomerulonephritis-- but with the UPCR at 0.2 it is in the borderline range.
There does not seem to be any evidence of neoplasia... but that possibility is lurking in the background for a cat with unexplained wt. loss!
I considered putting him on a low protein, low salt diet, but wondering if it is too early to even do this? Should I just suggest rechecking a UPCR in 2-4 months?
In the meantime I have suggested a good quality senior diet (Medical Senior consult) to ensure that he is getting appropriate calories.
Not sure anything else is indicated yet. Feel it may be too early to think about Benazepril.
I have warned the owners about possible neoplasia (intestinal?).
I did think about doing an FIV/FeLV test, but not sure how the answer would change my approach?
So I am just wondering where to go from here?
Any suggestions? Anything I have missed?
Appreciate your thoughts,
☼ | It is possible that there is something else going on though, maybe intestinal malabsorption? | Was she on dry duck and pea when she was initially on the pred? |
I saw Tucker last week for a presenting complaint of wt. loss and voracious appetite.
We have not seen him since 2010 but he had been apparently healthy in the last 3 years. Have just moved to new house- 3 wks ago. Tucker seems to be settling well. O has notice wt. loss in last 2 months. Voracious appetite, will now jump up on counters looking for food. Thinks his drinking might have incsed. Difficult to comment on U as has 2 other cats. No V/D.
GPE-BAR has lost 1 kg since last weighed (2010 but O feels wt was consistent until 2 months ago). eyes and ears-NAF, teeth- M2 tartar and gingivitis. Possible thickened tissue in a of thyroid? chest-NAF, Abdo-soft, comfortable, bladder is empty, kidneys-smooth. intestinal loops are soft, no masses palpable. LN-WNL, coat- excellent. good hind limb muscling.
wt=3.8 kg
T=38.1C
HR=240, regular rhythm, no murmurs
RR=60bpm
CRT2
BCS=2.5/5
GGH but unexplained wt. loss and incsed appetite, poss incse in drinking? R/O hyperthyroidism, diabetes, kidney or liver failure, glomerulonephritis.
Bladder was empty so no U sample obtained, did take blood for full chemistry, T4 and CBC.
Suggested once Blood results back should return for U sample if no diagnosis from blood results.
All biochemistry blood results were normal! T4 was normal at 48.6 nmol/L.
CBC was essentially all normal, the only abn being a mild lymphopenia - Lymphocytes 1.2 (N=1.5-7.0 X 10E9/L)
Tucker returned for collection of a U sample: need to give him SQ fluids to get him to produce as no bladder palpable when admitted.
The U results are as follows:
sp. gravity= 1.050
all stick pads were negative except for protein at 2+
No sediment visible after sample was centrifuged. Sample sent off for UPCR
URINE PROTEIN 67 mg/dl
URINE CREATININE 24810 umol/L
URINE PROTEIN/CREATININE RATIO 0.2 (0.0 - 0.2)
We did a BP measurement while in clinic: we did 3 measurements that ranged 125-130
From all the tests I have ruled out: Hyperthyroidism, renal/hepatic dz, diabetes.
I wondered about poss. glomerulonephritis-- but with the UPCR at 0.2 it is in the borderline range.
There does not seem to be any evidence of neoplasia... but that possibility is lurking in the background for a cat with unexplained wt. loss!
I considered putting him on a low protein, low salt diet, but wondering if it is too early to even do this? Should I just suggest rechecking a UPCR in 2-4 months?
In the meantime I have suggested a good quality senior diet (Medical Senior consult) to ensure that he is getting appropriate calories.
Not sure anything else is indicated yet. Feel it may be too early to think about Benazepril.
I have warned the owners about possible neoplasia (intestinal?).
I did think about doing an FIV/FeLV test, but not sure how the answer would change my approach?
So I am just wondering where to go from here?
Any suggestions? Anything I have missed?
Appreciate your thoughts,
☼ | Is the cat actually eating more than a normal cat or just wanting more food? | How many calories does he get per day currently? |
I saw Tucker last week for a presenting complaint of wt. loss and voracious appetite.
We have not seen him since 2010 but he had been apparently healthy in the last 3 years. Have just moved to new house- 3 wks ago. Tucker seems to be settling well. O has notice wt. loss in last 2 months. Voracious appetite, will now jump up on counters looking for food. Thinks his drinking might have incsed. Difficult to comment on U as has 2 other cats. No V/D.
GPE-BAR has lost 1 kg since last weighed (2010 but O feels wt was consistent until 2 months ago). eyes and ears-NAF, teeth- M2 tartar and gingivitis. Possible thickened tissue in a of thyroid? chest-NAF, Abdo-soft, comfortable, bladder is empty, kidneys-smooth. intestinal loops are soft, no masses palpable. LN-WNL, coat- excellent. good hind limb muscling.
wt=3.8 kg
T=38.1C
HR=240, regular rhythm, no murmurs
RR=60bpm
CRT2
BCS=2.5/5
GGH but unexplained wt. loss and incsed appetite, poss incse in drinking? R/O hyperthyroidism, diabetes, kidney or liver failure, glomerulonephritis.
Bladder was empty so no U sample obtained, did take blood for full chemistry, T4 and CBC.
Suggested once Blood results back should return for U sample if no diagnosis from blood results.
All biochemistry blood results were normal! T4 was normal at 48.6 nmol/L.
CBC was essentially all normal, the only abn being a mild lymphopenia - Lymphocytes 1.2 (N=1.5-7.0 X 10E9/L)
Tucker returned for collection of a U sample: need to give him SQ fluids to get him to produce as no bladder palpable when admitted.
The U results are as follows:
sp. gravity= 1.050
all stick pads were negative except for protein at 2+
No sediment visible after sample was centrifuged. Sample sent off for UPCR
URINE PROTEIN 67 mg/dl
URINE CREATININE 24810 umol/L
URINE PROTEIN/CREATININE RATIO 0.2 (0.0 - 0.2)
We did a BP measurement while in clinic: we did 3 measurements that ranged 125-130
From all the tests I have ruled out: Hyperthyroidism, renal/hepatic dz, diabetes.
I wondered about poss. glomerulonephritis-- but with the UPCR at 0.2 it is in the borderline range.
There does not seem to be any evidence of neoplasia... but that possibility is lurking in the background for a cat with unexplained wt. loss!
I considered putting him on a low protein, low salt diet, but wondering if it is too early to even do this? Should I just suggest rechecking a UPCR in 2-4 months?
In the meantime I have suggested a good quality senior diet (Medical Senior consult) to ensure that he is getting appropriate calories.
Not sure anything else is indicated yet. Feel it may be too early to think about Benazepril.
I have warned the owners about possible neoplasia (intestinal?).
I did think about doing an FIV/FeLV test, but not sure how the answer would change my approach?
So I am just wondering where to go from here?
Any suggestions? Anything I have missed?
Appreciate your thoughts,
☼ | Is the owner completely sure there is no vomiting somewhere that they misssed? | What diet is this gal eating? |
This may be a stupid question about anesthesia of a not well controlled diabetic.
Just saw an elderly 12# pomerianian diabetic on 5 units Humulin N BID with a history of chronic cough x 4 years.
I was originally planning on doing a bronchoscopy/BAL, but the morning BG (after a fast and no insulin yet) was only 83
Being a mobile internist, I was a little worried about general anesthesia and post-procedural monitoring, so I chickened out and just mildly sedated the dog for a tracheal wash instead. I suggested to the RDVM to decrease the dose to 3 units BID and to recheck a BG curve in 1 week.
If I were in a referral practice with monitoring that I could have controlled, I probably would have felt better about doing a BAL. So, I was just curious what the recommended protocol would have been if I hadn't chickened out.
I guess, start IV fluids with dextrose and then given a 1/2 dose of insulin when the BG > 250?
☼ | Had she had the insulin the morning of the procedure but no breakfast? | Is he also receiving prescription traditional prescription medications (rx & otc) as well as the supplements? |
I've been treating a 10 yr old cocker wtih PLE for the last 4 months with the help of an internist. He originally was on azathiaprin, pred, metronidazole. He had neuro signs on metronidazole so was changed to tylan/probiotics. His albumin dropped to about 1.2 and his Ca was so low that MSU was surprised he was alive
.
He was put on injectable dexamethasone 2mg SID (he weighs about 16# or so) and calcitriol. He responded well-felt great, eating, stool improved, gradual wt gain. After 2 weeks, his alb was 2.0 so we went to 2mg dex SQ q48 hrs. One wk later, his alb was still 2 so stable. He has been on q48 dex for 2 wks now and his stool is normal. I am worried about the side effects that the dex may have. I can't seem to contact the internist he sees.
This is a very abbreviated synopsis.
Can he stay on the injectable dex safely at q48 hrs? How long before changing back to oral pred or budesonide? What wash out for the dexamethasone-institute the new drug 48 hrs after the last dex dose?
Would you try budesonide over pred?
I haven't ever used inj dex this long and years ago saw someone elses IMHA cas get pancreatitis and diabetes after prolonged inj dex. I realize that using the inj dex was the turning point for him and he would have been euthanized otherwise becasue he was doing so poorly, however I want to try to avoid another problem.
Really appreciate your opinion. Thanks so much | What dose of azathioprine is he on? | I'm confused, is there still a urolith in the urethra or not? |
I've been treating a 10 yr old cocker wtih PLE for the last 4 months with the help of an internist. He originally was on azathiaprin, pred, metronidazole. He had neuro signs on metronidazole so was changed to tylan/probiotics. His albumin dropped to about 1.2 and his Ca was so low that MSU was surprised he was alive
.
He was put on injectable dexamethasone 2mg SID (he weighs about 16# or so) and calcitriol. He responded well-felt great, eating, stool improved, gradual wt gain. After 2 weeks, his alb was 2.0 so we went to 2mg dex SQ q48 hrs. One wk later, his alb was still 2 so stable. He has been on q48 dex for 2 wks now and his stool is normal. I am worried about the side effects that the dex may have. I can't seem to contact the internist he sees.
This is a very abbreviated synopsis.
Can he stay on the injectable dex safely at q48 hrs? How long before changing back to oral pred or budesonide? What wash out for the dexamethasone-institute the new drug 48 hrs after the last dex dose?
Would you try budesonide over pred?
I haven't ever used inj dex this long and years ago saw someone elses IMHA cas get pancreatitis and diabetes after prolonged inj dex. I realize that using the inj dex was the turning point for him and he would have been euthanized otherwise becasue he was doing so poorly, however I want to try to avoid another problem.
Really appreciate your opinion. Thanks so much | What's the current calcium level? | Is there pu/pd? |
I've been treating a 10 yr old cocker wtih PLE for the last 4 months with the help of an internist. He originally was on azathiaprin, pred, metronidazole. He had neuro signs on metronidazole so was changed to tylan/probiotics. His albumin dropped to about 1.2 and his Ca was so low that MSU was surprised he was alive
.
He was put on injectable dexamethasone 2mg SID (he weighs about 16# or so) and calcitriol. He responded well-felt great, eating, stool improved, gradual wt gain. After 2 weeks, his alb was 2.0 so we went to 2mg dex SQ q48 hrs. One wk later, his alb was still 2 so stable. He has been on q48 dex for 2 wks now and his stool is normal. I am worried about the side effects that the dex may have. I can't seem to contact the internist he sees.
This is a very abbreviated synopsis.
Can he stay on the injectable dex safely at q48 hrs? How long before changing back to oral pred or budesonide? What wash out for the dexamethasone-institute the new drug 48 hrs after the last dex dose?
Would you try budesonide over pred?
I haven't ever used inj dex this long and years ago saw someone elses IMHA cas get pancreatitis and diabetes after prolonged inj dex. I realize that using the inj dex was the turning point for him and he would have been euthanized otherwise becasue he was doing so poorly, however I want to try to avoid another problem.
Really appreciate your opinion. Thanks so much | Is he on cobalamin injections too? | Maybe on too high of a dose of flagyl? |
Hello,
Appreciate help with complicated case. Have been seeing "Snoop" , a 13.5lb NICE m/n minpin for few years. Hx 3 bouts IMHA over past 6 years (last bout 16 months ago). Always responded well to Pred and Imuran which o always completely discontinued against our suggestion each time once dog doing well for months. Dx with DM last year (suspect from Pred had been on in past) and well controlled on 7 units NPH BID. Last glucose curve wnl 2/13. Presented 4/9/13 for lethargy/white mm for FEW days (uuuugh!!!!) . BG 637, ketones in urine, PCV 14% and elevated WBC (25,000). Hospitalized for 5 days, started on Pred 10mg BID and Imuran 25mg SID and BG monitored. Ketones cleared in hosp and discharged on 12 units NPH BID with a PCV of 22%. Rechecked 5 days later- PCV 27% and increased NPH to 13 units. Rechecked 1 week later (yesterday) and PCV 28%, WBC wnl but now showing non-regenerative anemia (was regenerative on initial dx) Dog feels great at home. My question- why is there a non-regenerative anemia now? From Imuran? What to do about it to get the PCV higher? I did go ahead and decrease Pred to 5mg BID since PCV stable to try to get DM better regulated. Copy of last CBC:
RBC 3.16 M/μL 5.50 - 8.50 LOW * 1.58 M/μL
HCT 23.6 % 37.0 - 55.0 LOW * 11.9 %
HGB 8.6 g/dL 12.0 - 18.0 LOW 8.3 g/dL
MCV 74.8 fL 60.0 - 77.0 * 75.4 fL
MCH 27.1 pg 18.5 - 30.0 52.7 pg
MCHC 36.3 g/dL 30.0 - 37.5 --.-- g/dL
RDW 18.6 % 14.7 - 17.9 HIGH 19.0 %
%RETIC 1.8 % 12.2 %
RETIC 56.5 K/μL 10.0 - 110.0 193.5 K/μL
WBC 10.60 K/μL 5.50 - 16.90 23.95 K/μL
%NEU 75.6 % 71.5 %
%LYM 11.0 % 14.0 %
%MONO 10.2 % 11.5 %
%EOS 3.1 % 2.5 %
%BASO 0.2 % 0.5 %
NEU 8.02 K/μL 2.00 - 12.00 17.12 K/μL
LYM 1.16 K/μL 0.50 - 4.90 3.35 K/μL
MONO 1.08 K/μL 0.30 - 2.00 2.75 K/μL
EOS 0.33 K/μL 0.10 - 1.49 0.60 K/μL
BASO 0.02 K/μL 0.00 - 0.10 0.12 K/μL
PLT 968 K/μL 175 - 500 HIGH * 585 K/μL
MPV 13.1 fL * 29.5 fL
PDW 23.2 % 27.1 %
PCT 1.27 % * 1.72 % | When there is the regenerative anemia (what was the original retic count when the pcv was 14% and he was ketotic? | Can you test him with cortrosyn so we know? |
Hello,
Appreciate help with complicated case. Have been seeing "Snoop" , a 13.5lb NICE m/n minpin for few years. Hx 3 bouts IMHA over past 6 years (last bout 16 months ago). Always responded well to Pred and Imuran which o always completely discontinued against our suggestion each time once dog doing well for months. Dx with DM last year (suspect from Pred had been on in past) and well controlled on 7 units NPH BID. Last glucose curve wnl 2/13. Presented 4/9/13 for lethargy/white mm for FEW days (uuuugh!!!!) . BG 637, ketones in urine, PCV 14% and elevated WBC (25,000). Hospitalized for 5 days, started on Pred 10mg BID and Imuran 25mg SID and BG monitored. Ketones cleared in hosp and discharged on 12 units NPH BID with a PCV of 22%. Rechecked 5 days later- PCV 27% and increased NPH to 13 units. Rechecked 1 week later (yesterday) and PCV 28%, WBC wnl but now showing non-regenerative anemia (was regenerative on initial dx) Dog feels great at home. My question- why is there a non-regenerative anemia now? From Imuran? What to do about it to get the PCV higher? I did go ahead and decrease Pred to 5mg BID since PCV stable to try to get DM better regulated. Copy of last CBC:
RBC 3.16 M/μL 5.50 - 8.50 LOW * 1.58 M/μL
HCT 23.6 % 37.0 - 55.0 LOW * 11.9 %
HGB 8.6 g/dL 12.0 - 18.0 LOW 8.3 g/dL
MCV 74.8 fL 60.0 - 77.0 * 75.4 fL
MCH 27.1 pg 18.5 - 30.0 52.7 pg
MCHC 36.3 g/dL 30.0 - 37.5 --.-- g/dL
RDW 18.6 % 14.7 - 17.9 HIGH 19.0 %
%RETIC 1.8 % 12.2 %
RETIC 56.5 K/μL 10.0 - 110.0 193.5 K/μL
WBC 10.60 K/μL 5.50 - 16.90 23.95 K/μL
%NEU 75.6 % 71.5 %
%LYM 11.0 % 14.0 %
%MONO 10.2 % 11.5 %
%EOS 3.1 % 2.5 %
%BASO 0.2 % 0.5 %
NEU 8.02 K/μL 2.00 - 12.00 17.12 K/μL
LYM 1.16 K/μL 0.50 - 4.90 3.35 K/μL
MONO 1.08 K/μL 0.30 - 2.00 2.75 K/μL
EOS 0.33 K/μL 0.10 - 1.49 0.60 K/μL
BASO 0.02 K/μL 0.00 - 0.10 0.12 K/μL
PLT 968 K/μL 175 - 500 HIGH * 585 K/μL
MPV 13.1 fL * 29.5 fL
PDW 23.2 % 27.1 %
PCT 1.27 % * 1.72 % | Is that the 193,000 to the right of the normal range in your chart?), are there spherocytes/agglutination? | So, what is the dog's sleeping rr? |
Hello,
Appreciate help with complicated case. Have been seeing "Snoop" , a 13.5lb NICE m/n minpin for few years. Hx 3 bouts IMHA over past 6 years (last bout 16 months ago). Always responded well to Pred and Imuran which o always completely discontinued against our suggestion each time once dog doing well for months. Dx with DM last year (suspect from Pred had been on in past) and well controlled on 7 units NPH BID. Last glucose curve wnl 2/13. Presented 4/9/13 for lethargy/white mm for FEW days (uuuugh!!!!) . BG 637, ketones in urine, PCV 14% and elevated WBC (25,000). Hospitalized for 5 days, started on Pred 10mg BID and Imuran 25mg SID and BG monitored. Ketones cleared in hosp and discharged on 12 units NPH BID with a PCV of 22%. Rechecked 5 days later- PCV 27% and increased NPH to 13 units. Rechecked 1 week later (yesterday) and PCV 28%, WBC wnl but now showing non-regenerative anemia (was regenerative on initial dx) Dog feels great at home. My question- why is there a non-regenerative anemia now? From Imuran? What to do about it to get the PCV higher? I did go ahead and decrease Pred to 5mg BID since PCV stable to try to get DM better regulated. Copy of last CBC:
RBC 3.16 M/μL 5.50 - 8.50 LOW * 1.58 M/μL
HCT 23.6 % 37.0 - 55.0 LOW * 11.9 %
HGB 8.6 g/dL 12.0 - 18.0 LOW 8.3 g/dL
MCV 74.8 fL 60.0 - 77.0 * 75.4 fL
MCH 27.1 pg 18.5 - 30.0 52.7 pg
MCHC 36.3 g/dL 30.0 - 37.5 --.-- g/dL
RDW 18.6 % 14.7 - 17.9 HIGH 19.0 %
%RETIC 1.8 % 12.2 %
RETIC 56.5 K/μL 10.0 - 110.0 193.5 K/μL
WBC 10.60 K/μL 5.50 - 16.90 23.95 K/μL
%NEU 75.6 % 71.5 %
%LYM 11.0 % 14.0 %
%MONO 10.2 % 11.5 %
%EOS 3.1 % 2.5 %
%BASO 0.2 % 0.5 %
NEU 8.02 K/μL 2.00 - 12.00 17.12 K/μL
LYM 1.16 K/μL 0.50 - 4.90 3.35 K/μL
MONO 1.08 K/μL 0.30 - 2.00 2.75 K/μL
EOS 0.33 K/μL 0.10 - 1.49 0.60 K/μL
BASO 0.02 K/μL 0.00 - 0.10 0.12 K/μL
PLT 968 K/μL 175 - 500 HIGH * 585 K/μL
MPV 13.1 fL * 29.5 fL
PDW 23.2 % 27.1 %
PCT 1.27 % * 1.72 % | What was the total protein when the pcv was14% and now? | Can you give us some idea of the actual numbers the owner is generating? |
Hello,
Appreciate help with complicated case. Have been seeing "Snoop" , a 13.5lb NICE m/n minpin for few years. Hx 3 bouts IMHA over past 6 years (last bout 16 months ago). Always responded well to Pred and Imuran which o always completely discontinued against our suggestion each time once dog doing well for months. Dx with DM last year (suspect from Pred had been on in past) and well controlled on 7 units NPH BID. Last glucose curve wnl 2/13. Presented 4/9/13 for lethargy/white mm for FEW days (uuuugh!!!!) . BG 637, ketones in urine, PCV 14% and elevated WBC (25,000). Hospitalized for 5 days, started on Pred 10mg BID and Imuran 25mg SID and BG monitored. Ketones cleared in hosp and discharged on 12 units NPH BID with a PCV of 22%. Rechecked 5 days later- PCV 27% and increased NPH to 13 units. Rechecked 1 week later (yesterday) and PCV 28%, WBC wnl but now showing non-regenerative anemia (was regenerative on initial dx) Dog feels great at home. My question- why is there a non-regenerative anemia now? From Imuran? What to do about it to get the PCV higher? I did go ahead and decrease Pred to 5mg BID since PCV stable to try to get DM better regulated. Copy of last CBC:
RBC 3.16 M/μL 5.50 - 8.50 LOW * 1.58 M/μL
HCT 23.6 % 37.0 - 55.0 LOW * 11.9 %
HGB 8.6 g/dL 12.0 - 18.0 LOW 8.3 g/dL
MCV 74.8 fL 60.0 - 77.0 * 75.4 fL
MCH 27.1 pg 18.5 - 30.0 52.7 pg
MCHC 36.3 g/dL 30.0 - 37.5 --.-- g/dL
RDW 18.6 % 14.7 - 17.9 HIGH 19.0 %
%RETIC 1.8 % 12.2 %
RETIC 56.5 K/μL 10.0 - 110.0 193.5 K/μL
WBC 10.60 K/μL 5.50 - 16.90 23.95 K/μL
%NEU 75.6 % 71.5 %
%LYM 11.0 % 14.0 %
%MONO 10.2 % 11.5 %
%EOS 3.1 % 2.5 %
%BASO 0.2 % 0.5 %
NEU 8.02 K/μL 2.00 - 12.00 17.12 K/μL
LYM 1.16 K/μL 0.50 - 4.90 3.35 K/μL
MONO 1.08 K/μL 0.30 - 2.00 2.75 K/μL
EOS 0.33 K/μL 0.10 - 1.49 0.60 K/μL
BASO 0.02 K/μL 0.00 - 0.10 0.12 K/μL
PLT 968 K/μL 175 - 500 HIGH * 585 K/μL
MPV 13.1 fL * 29.5 fL
PDW 23.2 % 27.1 %
PCT 1.27 % * 1.72 % | Is there splenomegaly and icterus when the imha starts? | (i've been fooled with one of my own cats, sigh.) also, as catarracts are rare in cats and not associated with diabetes (unlike dogs and humans), could this be lenticular sclerosis? |
Hi there - I recently was introduced to "Carlos", a 6 year old male chihuahua. He was presented for 2 complaints:
1. diarrhea off and on for, I believe he said, the last 2 month. Also, he had variable appetite.
2. PU/PD, according to the owner, that has gone on for the last 3+ years.
He said he went to another vet in 2012 about the PU/PD, where they diagnosed him with anemia, put him on something called lixotinic (I assume a vitamin/iron supplement). He said he thought the PU/PD improved a wee bit, but when he ran out of the lixotinic, it came back. He went and refilled it, but to no effect the second time.
What I saw on physical exam was a very healthy looking little dog - no hair loss, no potbelly, good body weight, BAR. Mild dental tartar. Grade 4/4 medial patellar luxation in the one back leg, 3/4 in the other, No complaints of lameness. Vitals were normal. He was not on heartworm preventative, and vaccines booster were overdue. He didn't seem particularly high strung, he was quiet and friendly.
Current meds listed by the owner were lixotinic and comfortis.
I did not receive a copy of the previous vet's labwork. I went ahead and ran a fecal exam, and sent off a CBC/chemistry/Ua and thyroid. The fecal showed hookworms, so I dewormed with panacur, and when the heartworm came back negative, instructed him to start Trifexis in 2 weeks to get a second deworming. I would hope that takes care of the diarrhea.
I will copy and paste labs below:
Total Protein 7.6 5.0-7.4 g/dL HIGH
Albumin 3.3 2.7-4.4 g/dL
Globulin 4.3 1.6-3.6 g/dL HIGH
A/G Ratio 0.8 0.8-2.0 Ratio
AST (SGOT) 23 15-66 U/L
ALT (SGPT) 45 12-118 U/L
Alk Phosphatase 23 5-131 U/L
GGTP 6 1-12 U/L
Total Bilirubin 0.1 0.1-0.3 mg/dL
Urea Nitrogen 15 6-31 mg/dL
Creatinine 0.7 0.5-1.6 mg/dL
BUN/Creatinine Ratio 21 4-27 Ratio
Phosphorus 4.1 2.5-6.0 mg/dL
Glucose 121 70-138 mg/dL
Calcium 9.7 8.9-11.4 mg/dL
Corrected Calcium 9.9
Magnesium 1.8 1.5-2.5 mEq/L
Sodium 148 139-154 mEq/L
Potassium 5.4 3.6-5.5 mEq/L
Na/K Ratio 27
Chloride 115 102-120 mEq/L
Cholesterol 226 92-324 mg/dL
Triglycerides 53 29-291 mg/dL
Amylase 670 290-1125 U/L
Lipase 168 77-695 U/L
CPK 109 59-895 U/L
CBC
WBC 14.6 4.0-15.5 103/mL
RBC 6.08 4.8-9.3 106/mL
Hemoglobin 13.7 12.1-20.3 g/dL
Hematocrit 41.0 36-60 %
MCV 67 58-79 fL
MCH 22.5 19-28 pg
MCHC 33.4 30-38 g/dL
Platelet Count 480 170-400 103/mL HIGH
Platelet EST Increased Adequate
Differential Absolute %
Neutrophils 9198 63 2060-10600 /uL
Bands 0 0 0-300 /uL
Lymphocytes 2628 18 690-4500 /uL
Monocytes 730 5 0-840 /uL
Eosinophils 1898 13 0-1200 /uL HIGH
Basophils 146 1 0-150 /uL
Heartworm Antigen
Occult Heartworm Antigen Negative
There were no measurable amounts of adult female heartworm antigen in this sample. Adult Dirofilaria immitis antigens will not be detected for 5 to 7 months following exposure to early larval stages.
Total T4
T4 1.3 0.8-3.5 ug/dL
Note new Canine reference range
Urinalysis
Collection Method
Cystocentesis
Color Yellow
Appearance Hazy *Clear
Specific Gravity 1.005 1.015-1.050 LOW
pH 5.5 5.5-7.0
Protein Negative Neg
Glucose Negative Neg
Ketone Negative Neg
Bilirubin Negative Neg To 1+
Blood Negative Neg
WBC None 0-3 HPF
RBC None 0-3 HPF
Casts None Seen LPF
Crystals None Seen HPF
Bacteria None Seen None HPF
Epithelial Cells None Seen HPF
I called the owner and asked if I could get some more urine samples, to recheck the specific gravity several times. He brought me back samples with the time of day that they were collected:
4/22 - 8:40 am SG 1.023
1:30 pm 1.007
4:30 pm 1.004
4/23 - 1:45 pm 1.004
So I feel like what I am looking at is a dog that looks like he CAN concentrate his urine, at least a bit, by the fact that first thing in the morning, after he has been sleeping more and drinking less, his SG is better.
The globulin count is kinda interesting, but perhaps can be explained by having hookworms?
I have not cultured his urine, nor have I pursued Cushings. But I am dubious, given the physical exam and how quiet his urine is.
I questioned the owner hard about the possibility of psychogenic polydipsia. He said this dog is extremely attached to him, and is rarely away from the owner more than 30 minutes at a time. The owner lost his wife sometime in the last few years, but I don't know how much that might have affected the dog. I couldn't get a good feel of that from the owner.
What would you be thinking at this point? Is diabetes insipidus still to be considered, even with the one specific gravity of 1.023?
I know I should look at the serum osmolality, but when I read post about how to do that, I got a bit confused because of different formulas, and I could never find what was normal and what was abnormal. What formula and normals do you use for that?
p / DVM, Chattanooga, TN
"If this is paradise, I wish I had a lawnmower!"-David Byrne | I assume that the dog was off water overnight? | How well is she eating? |
Darcy is an approximately 6-year old Border Collie who was adopted from the SPCA 2 weeks prior to presenting to me. Weight: 36.1 pounds (16.4kg). The records from the SPCA show she had a round of doxycycline for kennel cough, and a round of Clavamox for a UTI. She was spayed about 5 weeks before adoption and also underwent a cystotomy to remove 4 large stones. She was placed in a foster home while recovering. The records don’t give more information other than to say her urine pH was 8.0 and her USG was 1.036.
Darcy came in to see me on April 9, 2013 because of weakness, lethargy, limping in her right pelvic limb, and decreased appetite. Her temperature was 104.7, she was about 8% dehydrated, she was very ataxic but had no neurologic deficits. She reacted painfully to right stifle palpation, but there was no swelling or wounds found, and no pain with spine palpation. I ran an in-house lab panel and found the following abnormalities:
CBC:
WBC: 4.95 K/ul (5.05 - 16.75) [band neutrophils suspected]
platelets 71 K/ul (148-484)
Her HCT was 40.1. I scanned a blood smear and found a large number of toxic neutrophils and a few bands. The platelet count did seem accurate, however Darcy had no evidence of clotting problems; no petechiae, etc.
Her chemistry values were all within the reference ranges, as were her electrolytes.
Na =150 (144-160)
K = 4.3 (3.5 - 5.8)
Unfortunately, I did not do a UA which in hindsight I wish I had. I started Darcy on IV fluids, injectable Baytril and ampicillin.
Abdominal radiographs were read by a radiologist and showed LS disc collapse and constipation.
By the afternoon her temperature was 101.4 and she wasn’t limping anymore. She wasn’t as ataxic, but still had no interest in food and was lethargic.
She went home the next day with the following oral medications and instructions for a bland diet.
Carprofen 37.5mg PO BID
Baytril 68mg PO SID
Amoxicillin 500mg PO BID
She did well at home and was back to normal in 48 hours. On April 16 I repeated her CBC:
WBC: 8.97 K/ul (5.05 - 16.75)
platelets: 295 K/ul (148-484)
So here’s what is going on now. On April 23 I get a call from the owner telling me that since going home on April 10 Darcy has been very PU/PD. She asks to go outside to urinate at least once an hour, although she is able to hold it overnight. She sometimes urinates large amounts and sometimes small amounts. I ran a urinalysis (via the outside laboratory) via cystocentesis and found the following:
SG: 1.002
pH: 7.0
rare epithelial cell
negative for bacteria, casts, crystals, protein, blood, glucose, etc.
Normally I run a urine culture but with the level of SG I was talked out of it. Her urine looked like water.
I had her withhold water from 8 pm until 8 am and had her drop off the first morning urine sample (free catch). The color was light yellow and the SG was 1.012. The owner told me that Darcy was pawing at the door all night to get to her water bowl. She also has measured water intake for 24 hours and tells me Darcy drank 8 cups of water. (I calculated about 6.5 cups/day as normal for a 16 kg dog)
Keep in mind that this o has been ‘complaining’ about the cost for everything so far given that it’s a rescue and she’s only had her for about a month by this time. I have talked about abdominal ultrasound, ACTH stim tests, chest radiographs, blood pressures, bile acids, and repeated labwork and she is very resistant.
So I am stumped. I have spent a few hours on VIN looking for all those pearls of wisdom. I think that if I have more ammunition to push for tests she MIGHT go for it. I printed out the DDx for PU/PD and did my list of eliminated, possible, and unlikely.
Here is what I have:
Unlikely: (I admit I’m basing this on a normal chemistry panel, although I don’t have an abdominal ultrasound as of yet)
Hyperadrenocorticism
Liver disease
Pyelonephritis
Leptospirosis (also given history of Clavamox and doxycycline)
Renal disease
Pericardial effusion
Possible:
Hypoadrenocorticism: (Atypical) possible, although I would expect her to pretty sick by now.
Hypothyroidism (no other symptoms but haven’t run it yet. yes, I will do that soon).
Paraneoplastic syndrome
Psychogenic PD or non-medical PD (this is high on my list)
Diabetes Insipidus (I would think very possible but not sure if USG would be 1.012 after 12 hours of water deprivation.
Hypertension
Ruled out:
Hypercalcemia
Diabetes Mellitus
Hypokalemia
Pyometra
Renal Tubular Disease
Urinary obstruction
Iatrogenic
Polycythemia
Acromegaly
The owner is wondering if there could be a connection with the cystotomy (done at the end of February) and bladder weakness. I don’t think it is likely but I didn’t do the surgery and I have no idea what “large bladder stones” actually translates to in size.
She says sometimes it looks like Darcy is ‘leaking’ urine, but then says she can hold it if she needs to. She says that there is never a wet spot where Darcy has been lying, so I'm less inclined to think this is incontinence. She started having accidents in the house yesterday and today. I am trying to prioritize (hah!) my recommendations because of cost. The owner knows about Desmopressin and is interested in that, even with the cost. I have cautioned her about hyponatremia and regular monitoring of her electrolytes.
Is there anything I am missing? I still am not sure what caused her original illness with me; the fever, leukopenia and thrombocytopenia. I thought maybe a bone marrow insult but not sure to what - trauma? medications? infection? I think I could talk her into another chemistry panel and T4, but beyond that it will be very difficult. I don’t want to start Desmopressin drops if I will do more harm than good. I realize from reading the posts of others that this isn’t an easy situation. Would it be harmful to start the eye drops with the condition that I check her labwork (chemistry, electrolytes) every 3 months? More often if she isn’t doing well? If Cushing’s does develop with more ‘proof’ of my suspicions I may be able to get her to do an ultrasound or Stim test.
Sorry about the long post and thank you for your help. I don’t usually post unless I am very, very stumped but I want to do what’s best for Darcy. Too bad I have to actually charge for what the best would be.
☼ | When she came in on 4/23, was she still on the antibiotics? | How is his appetite and stool quality? |
Darcy is an approximately 6-year old Border Collie who was adopted from the SPCA 2 weeks prior to presenting to me. Weight: 36.1 pounds (16.4kg). The records from the SPCA show she had a round of doxycycline for kennel cough, and a round of Clavamox for a UTI. She was spayed about 5 weeks before adoption and also underwent a cystotomy to remove 4 large stones. She was placed in a foster home while recovering. The records don’t give more information other than to say her urine pH was 8.0 and her USG was 1.036.
Darcy came in to see me on April 9, 2013 because of weakness, lethargy, limping in her right pelvic limb, and decreased appetite. Her temperature was 104.7, she was about 8% dehydrated, she was very ataxic but had no neurologic deficits. She reacted painfully to right stifle palpation, but there was no swelling or wounds found, and no pain with spine palpation. I ran an in-house lab panel and found the following abnormalities:
CBC:
WBC: 4.95 K/ul (5.05 - 16.75) [band neutrophils suspected]
platelets 71 K/ul (148-484)
Her HCT was 40.1. I scanned a blood smear and found a large number of toxic neutrophils and a few bands. The platelet count did seem accurate, however Darcy had no evidence of clotting problems; no petechiae, etc.
Her chemistry values were all within the reference ranges, as were her electrolytes.
Na =150 (144-160)
K = 4.3 (3.5 - 5.8)
Unfortunately, I did not do a UA which in hindsight I wish I had. I started Darcy on IV fluids, injectable Baytril and ampicillin.
Abdominal radiographs were read by a radiologist and showed LS disc collapse and constipation.
By the afternoon her temperature was 101.4 and she wasn’t limping anymore. She wasn’t as ataxic, but still had no interest in food and was lethargic.
She went home the next day with the following oral medications and instructions for a bland diet.
Carprofen 37.5mg PO BID
Baytril 68mg PO SID
Amoxicillin 500mg PO BID
She did well at home and was back to normal in 48 hours. On April 16 I repeated her CBC:
WBC: 8.97 K/ul (5.05 - 16.75)
platelets: 295 K/ul (148-484)
So here’s what is going on now. On April 23 I get a call from the owner telling me that since going home on April 10 Darcy has been very PU/PD. She asks to go outside to urinate at least once an hour, although she is able to hold it overnight. She sometimes urinates large amounts and sometimes small amounts. I ran a urinalysis (via the outside laboratory) via cystocentesis and found the following:
SG: 1.002
pH: 7.0
rare epithelial cell
negative for bacteria, casts, crystals, protein, blood, glucose, etc.
Normally I run a urine culture but with the level of SG I was talked out of it. Her urine looked like water.
I had her withhold water from 8 pm until 8 am and had her drop off the first morning urine sample (free catch). The color was light yellow and the SG was 1.012. The owner told me that Darcy was pawing at the door all night to get to her water bowl. She also has measured water intake for 24 hours and tells me Darcy drank 8 cups of water. (I calculated about 6.5 cups/day as normal for a 16 kg dog)
Keep in mind that this o has been ‘complaining’ about the cost for everything so far given that it’s a rescue and she’s only had her for about a month by this time. I have talked about abdominal ultrasound, ACTH stim tests, chest radiographs, blood pressures, bile acids, and repeated labwork and she is very resistant.
So I am stumped. I have spent a few hours on VIN looking for all those pearls of wisdom. I think that if I have more ammunition to push for tests she MIGHT go for it. I printed out the DDx for PU/PD and did my list of eliminated, possible, and unlikely.
Here is what I have:
Unlikely: (I admit I’m basing this on a normal chemistry panel, although I don’t have an abdominal ultrasound as of yet)
Hyperadrenocorticism
Liver disease
Pyelonephritis
Leptospirosis (also given history of Clavamox and doxycycline)
Renal disease
Pericardial effusion
Possible:
Hypoadrenocorticism: (Atypical) possible, although I would expect her to pretty sick by now.
Hypothyroidism (no other symptoms but haven’t run it yet. yes, I will do that soon).
Paraneoplastic syndrome
Psychogenic PD or non-medical PD (this is high on my list)
Diabetes Insipidus (I would think very possible but not sure if USG would be 1.012 after 12 hours of water deprivation.
Hypertension
Ruled out:
Hypercalcemia
Diabetes Mellitus
Hypokalemia
Pyometra
Renal Tubular Disease
Urinary obstruction
Iatrogenic
Polycythemia
Acromegaly
The owner is wondering if there could be a connection with the cystotomy (done at the end of February) and bladder weakness. I don’t think it is likely but I didn’t do the surgery and I have no idea what “large bladder stones” actually translates to in size.
She says sometimes it looks like Darcy is ‘leaking’ urine, but then says she can hold it if she needs to. She says that there is never a wet spot where Darcy has been lying, so I'm less inclined to think this is incontinence. She started having accidents in the house yesterday and today. I am trying to prioritize (hah!) my recommendations because of cost. The owner knows about Desmopressin and is interested in that, even with the cost. I have cautioned her about hyponatremia and regular monitoring of her electrolytes.
Is there anything I am missing? I still am not sure what caused her original illness with me; the fever, leukopenia and thrombocytopenia. I thought maybe a bone marrow insult but not sure to what - trauma? medications? infection? I think I could talk her into another chemistry panel and T4, but beyond that it will be very difficult. I don’t want to start Desmopressin drops if I will do more harm than good. I realize from reading the posts of others that this isn’t an easy situation. Would it be harmful to start the eye drops with the condition that I check her labwork (chemistry, electrolytes) every 3 months? More often if she isn’t doing well? If Cushing’s does develop with more ‘proof’ of my suspicions I may be able to get her to do an ultrasound or Stim test.
Sorry about the long post and thank you for your help. I don’t usually post unless I am very, very stumped but I want to do what’s best for Darcy. Too bad I have to actually charge for what the best would be.
☼ | It can really help with the costs for all this if you can get set up to start the cultures in-house---any chance of this? | The owner can accurately measure and then inject the insulin--using u40 syringes? |
Darcy is an approximately 6-year old Border Collie who was adopted from the SPCA 2 weeks prior to presenting to me. Weight: 36.1 pounds (16.4kg). The records from the SPCA show she had a round of doxycycline for kennel cough, and a round of Clavamox for a UTI. She was spayed about 5 weeks before adoption and also underwent a cystotomy to remove 4 large stones. She was placed in a foster home while recovering. The records don’t give more information other than to say her urine pH was 8.0 and her USG was 1.036.
Darcy came in to see me on April 9, 2013 because of weakness, lethargy, limping in her right pelvic limb, and decreased appetite. Her temperature was 104.7, she was about 8% dehydrated, she was very ataxic but had no neurologic deficits. She reacted painfully to right stifle palpation, but there was no swelling or wounds found, and no pain with spine palpation. I ran an in-house lab panel and found the following abnormalities:
CBC:
WBC: 4.95 K/ul (5.05 - 16.75) [band neutrophils suspected]
platelets 71 K/ul (148-484)
Her HCT was 40.1. I scanned a blood smear and found a large number of toxic neutrophils and a few bands. The platelet count did seem accurate, however Darcy had no evidence of clotting problems; no petechiae, etc.
Her chemistry values were all within the reference ranges, as were her electrolytes.
Na =150 (144-160)
K = 4.3 (3.5 - 5.8)
Unfortunately, I did not do a UA which in hindsight I wish I had. I started Darcy on IV fluids, injectable Baytril and ampicillin.
Abdominal radiographs were read by a radiologist and showed LS disc collapse and constipation.
By the afternoon her temperature was 101.4 and she wasn’t limping anymore. She wasn’t as ataxic, but still had no interest in food and was lethargic.
She went home the next day with the following oral medications and instructions for a bland diet.
Carprofen 37.5mg PO BID
Baytril 68mg PO SID
Amoxicillin 500mg PO BID
She did well at home and was back to normal in 48 hours. On April 16 I repeated her CBC:
WBC: 8.97 K/ul (5.05 - 16.75)
platelets: 295 K/ul (148-484)
So here’s what is going on now. On April 23 I get a call from the owner telling me that since going home on April 10 Darcy has been very PU/PD. She asks to go outside to urinate at least once an hour, although she is able to hold it overnight. She sometimes urinates large amounts and sometimes small amounts. I ran a urinalysis (via the outside laboratory) via cystocentesis and found the following:
SG: 1.002
pH: 7.0
rare epithelial cell
negative for bacteria, casts, crystals, protein, blood, glucose, etc.
Normally I run a urine culture but with the level of SG I was talked out of it. Her urine looked like water.
I had her withhold water from 8 pm until 8 am and had her drop off the first morning urine sample (free catch). The color was light yellow and the SG was 1.012. The owner told me that Darcy was pawing at the door all night to get to her water bowl. She also has measured water intake for 24 hours and tells me Darcy drank 8 cups of water. (I calculated about 6.5 cups/day as normal for a 16 kg dog)
Keep in mind that this o has been ‘complaining’ about the cost for everything so far given that it’s a rescue and she’s only had her for about a month by this time. I have talked about abdominal ultrasound, ACTH stim tests, chest radiographs, blood pressures, bile acids, and repeated labwork and she is very resistant.
So I am stumped. I have spent a few hours on VIN looking for all those pearls of wisdom. I think that if I have more ammunition to push for tests she MIGHT go for it. I printed out the DDx for PU/PD and did my list of eliminated, possible, and unlikely.
Here is what I have:
Unlikely: (I admit I’m basing this on a normal chemistry panel, although I don’t have an abdominal ultrasound as of yet)
Hyperadrenocorticism
Liver disease
Pyelonephritis
Leptospirosis (also given history of Clavamox and doxycycline)
Renal disease
Pericardial effusion
Possible:
Hypoadrenocorticism: (Atypical) possible, although I would expect her to pretty sick by now.
Hypothyroidism (no other symptoms but haven’t run it yet. yes, I will do that soon).
Paraneoplastic syndrome
Psychogenic PD or non-medical PD (this is high on my list)
Diabetes Insipidus (I would think very possible but not sure if USG would be 1.012 after 12 hours of water deprivation.
Hypertension
Ruled out:
Hypercalcemia
Diabetes Mellitus
Hypokalemia
Pyometra
Renal Tubular Disease
Urinary obstruction
Iatrogenic
Polycythemia
Acromegaly
The owner is wondering if there could be a connection with the cystotomy (done at the end of February) and bladder weakness. I don’t think it is likely but I didn’t do the surgery and I have no idea what “large bladder stones” actually translates to in size.
She says sometimes it looks like Darcy is ‘leaking’ urine, but then says she can hold it if she needs to. She says that there is never a wet spot where Darcy has been lying, so I'm less inclined to think this is incontinence. She started having accidents in the house yesterday and today. I am trying to prioritize (hah!) my recommendations because of cost. The owner knows about Desmopressin and is interested in that, even with the cost. I have cautioned her about hyponatremia and regular monitoring of her electrolytes.
Is there anything I am missing? I still am not sure what caused her original illness with me; the fever, leukopenia and thrombocytopenia. I thought maybe a bone marrow insult but not sure to what - trauma? medications? infection? I think I could talk her into another chemistry panel and T4, but beyond that it will be very difficult. I don’t want to start Desmopressin drops if I will do more harm than good. I realize from reading the posts of others that this isn’t an easy situation. Would it be harmful to start the eye drops with the condition that I check her labwork (chemistry, electrolytes) every 3 months? More often if she isn’t doing well? If Cushing’s does develop with more ‘proof’ of my suspicions I may be able to get her to do an ultrasound or Stim test.
Sorry about the long post and thank you for your help. I don’t usually post unless I am very, very stumped but I want to do what’s best for Darcy. Too bad I have to actually charge for what the best would be.
☼ | I'm not sure what caused her febrile episode, but she really sounded septic (with the left shift, thrombocytopenia, etc)---- wonder if she had a septic arthritis causing the pain? | Might represent bronchiectasis or bullae or an overinflated lung lobe? |
Darcy is an approximately 6-year old Border Collie who was adopted from the SPCA 2 weeks prior to presenting to me. Weight: 36.1 pounds (16.4kg). The records from the SPCA show she had a round of doxycycline for kennel cough, and a round of Clavamox for a UTI. She was spayed about 5 weeks before adoption and also underwent a cystotomy to remove 4 large stones. She was placed in a foster home while recovering. The records don’t give more information other than to say her urine pH was 8.0 and her USG was 1.036.
Darcy came in to see me on April 9, 2013 because of weakness, lethargy, limping in her right pelvic limb, and decreased appetite. Her temperature was 104.7, she was about 8% dehydrated, she was very ataxic but had no neurologic deficits. She reacted painfully to right stifle palpation, but there was no swelling or wounds found, and no pain with spine palpation. I ran an in-house lab panel and found the following abnormalities:
CBC:
WBC: 4.95 K/ul (5.05 - 16.75) [band neutrophils suspected]
platelets 71 K/ul (148-484)
Her HCT was 40.1. I scanned a blood smear and found a large number of toxic neutrophils and a few bands. The platelet count did seem accurate, however Darcy had no evidence of clotting problems; no petechiae, etc.
Her chemistry values were all within the reference ranges, as were her electrolytes.
Na =150 (144-160)
K = 4.3 (3.5 - 5.8)
Unfortunately, I did not do a UA which in hindsight I wish I had. I started Darcy on IV fluids, injectable Baytril and ampicillin.
Abdominal radiographs were read by a radiologist and showed LS disc collapse and constipation.
By the afternoon her temperature was 101.4 and she wasn’t limping anymore. She wasn’t as ataxic, but still had no interest in food and was lethargic.
She went home the next day with the following oral medications and instructions for a bland diet.
Carprofen 37.5mg PO BID
Baytril 68mg PO SID
Amoxicillin 500mg PO BID
She did well at home and was back to normal in 48 hours. On April 16 I repeated her CBC:
WBC: 8.97 K/ul (5.05 - 16.75)
platelets: 295 K/ul (148-484)
So here’s what is going on now. On April 23 I get a call from the owner telling me that since going home on April 10 Darcy has been very PU/PD. She asks to go outside to urinate at least once an hour, although she is able to hold it overnight. She sometimes urinates large amounts and sometimes small amounts. I ran a urinalysis (via the outside laboratory) via cystocentesis and found the following:
SG: 1.002
pH: 7.0
rare epithelial cell
negative for bacteria, casts, crystals, protein, blood, glucose, etc.
Normally I run a urine culture but with the level of SG I was talked out of it. Her urine looked like water.
I had her withhold water from 8 pm until 8 am and had her drop off the first morning urine sample (free catch). The color was light yellow and the SG was 1.012. The owner told me that Darcy was pawing at the door all night to get to her water bowl. She also has measured water intake for 24 hours and tells me Darcy drank 8 cups of water. (I calculated about 6.5 cups/day as normal for a 16 kg dog)
Keep in mind that this o has been ‘complaining’ about the cost for everything so far given that it’s a rescue and she’s only had her for about a month by this time. I have talked about abdominal ultrasound, ACTH stim tests, chest radiographs, blood pressures, bile acids, and repeated labwork and she is very resistant.
So I am stumped. I have spent a few hours on VIN looking for all those pearls of wisdom. I think that if I have more ammunition to push for tests she MIGHT go for it. I printed out the DDx for PU/PD and did my list of eliminated, possible, and unlikely.
Here is what I have:
Unlikely: (I admit I’m basing this on a normal chemistry panel, although I don’t have an abdominal ultrasound as of yet)
Hyperadrenocorticism
Liver disease
Pyelonephritis
Leptospirosis (also given history of Clavamox and doxycycline)
Renal disease
Pericardial effusion
Possible:
Hypoadrenocorticism: (Atypical) possible, although I would expect her to pretty sick by now.
Hypothyroidism (no other symptoms but haven’t run it yet. yes, I will do that soon).
Paraneoplastic syndrome
Psychogenic PD or non-medical PD (this is high on my list)
Diabetes Insipidus (I would think very possible but not sure if USG would be 1.012 after 12 hours of water deprivation.
Hypertension
Ruled out:
Hypercalcemia
Diabetes Mellitus
Hypokalemia
Pyometra
Renal Tubular Disease
Urinary obstruction
Iatrogenic
Polycythemia
Acromegaly
The owner is wondering if there could be a connection with the cystotomy (done at the end of February) and bladder weakness. I don’t think it is likely but I didn’t do the surgery and I have no idea what “large bladder stones” actually translates to in size.
She says sometimes it looks like Darcy is ‘leaking’ urine, but then says she can hold it if she needs to. She says that there is never a wet spot where Darcy has been lying, so I'm less inclined to think this is incontinence. She started having accidents in the house yesterday and today. I am trying to prioritize (hah!) my recommendations because of cost. The owner knows about Desmopressin and is interested in that, even with the cost. I have cautioned her about hyponatremia and regular monitoring of her electrolytes.
Is there anything I am missing? I still am not sure what caused her original illness with me; the fever, leukopenia and thrombocytopenia. I thought maybe a bone marrow insult but not sure to what - trauma? medications? infection? I think I could talk her into another chemistry panel and T4, but beyond that it will be very difficult. I don’t want to start Desmopressin drops if I will do more harm than good. I realize from reading the posts of others that this isn’t an easy situation. Would it be harmful to start the eye drops with the condition that I check her labwork (chemistry, electrolytes) every 3 months? More often if she isn’t doing well? If Cushing’s does develop with more ‘proof’ of my suspicions I may be able to get her to do an ultrasound or Stim test.
Sorry about the long post and thank you for your help. I don’t usually post unless I am very, very stumped but I want to do what’s best for Darcy. Too bad I have to actually charge for what the best would be.
☼ | Can you give us all the results for the chem screen? | How did she respond to the 15 mg per day dose? |
We had a 2 year old F/S Terrier mix come in lethargic, shaking and ataxic on March 13th. No history of toxicity. We did bloodwork and found the following abnormalities: Cholesterol - 95, BUN-30, and ALT >1000. CBC, T4 and the rest of the CHEM 17 and electrolytes were normal.
We treated Sophie with Lactulose and metronidazole and she improved rapidly. We repeated an ALT 2 weeks later and it was 612. 3 Weeks after that we send an ALT out and it was 1993.
At this state we did a Bile acid. The dog wouldn't eat so I was about to have the owner bring it home to feed it but my tech found he liked Bil Jac liver treats so he was fed a small bowl of them (1 box).
The results were resting= 0.0, 2 hour post mega bil jac treats - 18
I think its time for an ultrasound and eventually liver biopsy (surgically) but I thought I would check here first since I pay for the service!! lol (actually I'm getting used to the saying, "first thought wrong!")
Thanks,
☼ | So still no back-story to report since the initial event? | I can't quite tell from your message whether the glipizide is actually working or not? |
We had a 2 year old F/S Terrier mix come in lethargic, shaking and ataxic on March 13th. No history of toxicity. We did bloodwork and found the following abnormalities: Cholesterol - 95, BUN-30, and ALT >1000. CBC, T4 and the rest of the CHEM 17 and electrolytes were normal.
We treated Sophie with Lactulose and metronidazole and she improved rapidly. We repeated an ALT 2 weeks later and it was 612. 3 Weeks after that we send an ALT out and it was 1993.
At this state we did a Bile acid. The dog wouldn't eat so I was about to have the owner bring it home to feed it but my tech found he liked Bil Jac liver treats so he was fed a small bowl of them (1 box).
The results were resting= 0.0, 2 hour post mega bil jac treats - 18
I think its time for an ultrasound and eventually liver biopsy (surgically) but I thought I would check here first since I pay for the service!! lol (actually I'm getting used to the saying, "first thought wrong!")
Thanks,
☼ | Nothing come to light that bears mentioning? | Is the dog on a high fiber diet? |
We had a 2 year old F/S Terrier mix come in lethargic, shaking and ataxic on March 13th. No history of toxicity. We did bloodwork and found the following abnormalities: Cholesterol - 95, BUN-30, and ALT >1000. CBC, T4 and the rest of the CHEM 17 and electrolytes were normal.
We treated Sophie with Lactulose and metronidazole and she improved rapidly. We repeated an ALT 2 weeks later and it was 612. 3 Weeks after that we send an ALT out and it was 1993.
At this state we did a Bile acid. The dog wouldn't eat so I was about to have the owner bring it home to feed it but my tech found he liked Bil Jac liver treats so he was fed a small bowl of them (1 box).
The results were resting= 0.0, 2 hour post mega bil jac treats - 18
I think its time for an ultrasound and eventually liver biopsy (surgically) but I thought I would check here first since I pay for the service!! lol (actually I'm getting used to the saying, "first thought wrong!")
Thanks,
☼ | Any possibility for leptospirosis in your area? | Acute on chronic oa? |
We had a 2 year old F/S Terrier mix come in lethargic, shaking and ataxic on March 13th. No history of toxicity. We did bloodwork and found the following abnormalities: Cholesterol - 95, BUN-30, and ALT >1000. CBC, T4 and the rest of the CHEM 17 and electrolytes were normal.
We treated Sophie with Lactulose and metronidazole and she improved rapidly. We repeated an ALT 2 weeks later and it was 612. 3 Weeks after that we send an ALT out and it was 1993.
At this state we did a Bile acid. The dog wouldn't eat so I was about to have the owner bring it home to feed it but my tech found he liked Bil Jac liver treats so he was fed a small bowl of them (1 box).
The results were resting= 0.0, 2 hour post mega bil jac treats - 18
I think its time for an ultrasound and eventually liver biopsy (surgically) but I thought I would check here first since I pay for the service!! lol (actually I'm getting used to the saying, "first thought wrong!")
Thanks,
☼ | Other health issues of note? | How does the chicken get prepared? |
We had a 2 year old F/S Terrier mix come in lethargic, shaking and ataxic on March 13th. No history of toxicity. We did bloodwork and found the following abnormalities: Cholesterol - 95, BUN-30, and ALT >1000. CBC, T4 and the rest of the CHEM 17 and electrolytes were normal.
We treated Sophie with Lactulose and metronidazole and she improved rapidly. We repeated an ALT 2 weeks later and it was 612. 3 Weeks after that we send an ALT out and it was 1993.
At this state we did a Bile acid. The dog wouldn't eat so I was about to have the owner bring it home to feed it but my tech found he liked Bil Jac liver treats so he was fed a small bowl of them (1 box).
The results were resting= 0.0, 2 hour post mega bil jac treats - 18
I think its time for an ultrasound and eventually liver biopsy (surgically) but I thought I would check here first since I pay for the service!! lol (actually I'm getting used to the saying, "first thought wrong!")
Thanks,
☼ | Do you have "full" laboratory results to post for us? | How many calories? |
That's not actually my question, just a little rant.
My real question: My patient is a 10-year-old spayed Puggle. She was diagnosed as diabetic at another clinic and put on insulin, but a glucose curve was (apparently) never run. Client came to us because the dog is PU/PD. Incidentally, she also has mature cataracts OU. We did a CBC, Chem 25 and UA. BG on this test was normal (104) but Alk phos was 1512. I want to make sure doggie is well-regulated before I test for Cushing's, so I ran a curve.
Sissy was given 6 units of Novolin-N insulin at 8:00 AM. Was fed at 8:00 AM. Gives insulin twice a day.
When she presented she was very nervous, had to be muzzled for each blood draw, and would not stop barking all day.
BLOOD GLUCOSE
9:00 AM: 403 mg/dL
11:00 AM: 154 mg/dL
1:00 PM: 210 mg/dL
3:00 PM: 264 mg/dL
5:00 PM: 121 mg/dL
6:30 PM: 107 mg/dL
My gut feel is that I should exclude the first value due to stress. The other values are kind of an upside-down curve but the nadir is where I want it to be. Can any endocrinology guru shed any light and make a recommendation on what should be done next? BTW, I don't think the client can do blood sugars at home.
Thanks a million! | But overall, the curve looks fantastic and i imagine clinically she's not very pu/pd or polyphagic? | And do have lepto where you are? |
In April 2012, Jake, a7 yr old mn dsh cat (11#11oz) , presented with pu/pd, weight loss and plantigrade stance. He was diagnosed with diabetes (glu 405, cbc/pro: nsf otherwise, urine c/s neg) and started on Lantus insulin. Attempted to regulate him on q 12 hr dosing thru Aug 2012 with curves that consistently showed him hovering at or below 100, fructosamine at that time (on 1 unit Lantus bid) was 227 (250- prolonged hypoglycemia). By that time, his weight had stabilized at 12.5# and his plantigrade stance was almost 100% improved. I discontinued his Lantus at that time.
At his annual exam in late March, now 13#, his glucose was again 376, though he is asymptomatic for diabetes. He was eating 2-3oz cans of moist food per day and 15-20 kibbles of dry food, so I discontinued all dry and he has been eating all canned food for 3 weeks. His glucose today was 287 mg/dl (71-159 normal). He has not received any Lantus since August of 2012.
At this point, do I start a low dose of Lantus or would home blood glucose monitoring give me a more realistic picture of his stress-free blood glucose? His weight is decr 6oz over the last month, but I have cut out his dry food also. His owner reports he is very normal at home and his litterbox doesn't appear more wet than usual.
If recommending at home monitoring, is the Alpha Trak the meter to use or any other recommendations: diet?
Thank you for any suggestions. | What brands/types of canned food? | Do they have strict anti-smuggling policies? |
In April 2012, Jake, a7 yr old mn dsh cat (11#11oz) , presented with pu/pd, weight loss and plantigrade stance. He was diagnosed with diabetes (glu 405, cbc/pro: nsf otherwise, urine c/s neg) and started on Lantus insulin. Attempted to regulate him on q 12 hr dosing thru Aug 2012 with curves that consistently showed him hovering at or below 100, fructosamine at that time (on 1 unit Lantus bid) was 227 (250- prolonged hypoglycemia). By that time, his weight had stabilized at 12.5# and his plantigrade stance was almost 100% improved. I discontinued his Lantus at that time.
At his annual exam in late March, now 13#, his glucose was again 376, though he is asymptomatic for diabetes. He was eating 2-3oz cans of moist food per day and 15-20 kibbles of dry food, so I discontinued all dry and he has been eating all canned food for 3 weeks. His glucose today was 287 mg/dl (71-159 normal). He has not received any Lantus since August of 2012.
At this point, do I start a low dose of Lantus or would home blood glucose monitoring give me a more realistic picture of his stress-free blood glucose? His weight is decr 6oz over the last month, but I have cut out his dry food also. His owner reports he is very normal at home and his litterbox doesn't appear more wet than usual.
If recommending at home monitoring, is the Alpha Trak the meter to use or any other recommendations: diet?
Thank you for any suggestions. | All low carb, 7% carbs? | How advanced are your dental capabilities? |