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We have a 10 year old yorkshire terrier that we have switched to Levemir insulin due to poor management with Humulin. He was started at 1 unit BID with a GC in the 300's. We increased it to 3 units BID. He was clinically managed well, no PU/PD, eating well, very active. The owner said he was acting the best he had in a long time, but was acting very hungry. At the next GC values were... 8:30 am= 122 mg/dL, 10:30= fed normal meal/given 3 units SQ and 123 mg/dL, 12:30= 429 mg/dL, 2:30= 226 mg/dL, 4:30= 183 mg/dL. All blood draws were clean sticks and AlphaTRAK was used on all. Postprandial glucose surge? Any suggestions? | When does he normally get the food/insulin at home? | He gets no dry food? |
I have a 10 year old Springer on Incurin for urinary incontinence (actually put on by my associate).
Pet parent called last night. Since on the incurin the dog is always hungry and food aggressive.
She was food aggessive with foster family 7 years ago prior to adoption but has never been with current family.
I could see how estrogen could do this but never heard of it. I do not have a lot of experience with incurin but have had a few pets on DES prior and never seen this.
We have recent labs- should be repeat labs and urine or change to prion?
/p | Have you reported this to the company? | Dog getting regular exercise? |
Happy weekend!
One of our great clients was in today picking up food and let me know her cat Magy has been humping his toys multiple times throughout the day, and she will find a few drops of a white-ish clear liquid, sometimes with a spot of blood. He is neutered (at 2 years of age), indoor/outdoor, and there are 2 other cats at home - 1 has been there for many years, and there is a new young f/s cat as well (introduced Oct 2012)- all seem to get along quite well. He never humps the other cats or his people.
He is well maintained on Glargine 2 iu BID, Purina DM kibble + canned, and he also gets Glucobay BID prior to a meal.
We recently diagnosed him with hyperthyroidism (Sept 2012) and started him on Tapazole 1/2 tab BID. At last T4 recheck it was at the very upper end of the ref range (59, ref 10-60), so we increased to 1 tab in AM, 1/2 tab in PM. Due for repeat T4 this week or next.
His owner thinks the humping started around the same time we started the Tapazole, although previously each spring he would have a few weeks of the occasional hump of his stuffed toy - nothing close to what he's been doing recently.
Any thoughts?
I'm concerned about a possible hormonal/adrenal disease going on, but was wondering if anyone's ever seen this behaviour once the hyperthyroidism started being treated? Or could it be related to the new younger cat in the household?
He's coming in next week for an exam and repeat blood, and his owner is game to do any hormone panels or extra testing required - she's the jackpot of cat owners!
Any thoughts/recommendations appreciated!
Thanks in advance, | How well is magy's glucose controlled? | How often do you feed her? |
"Onyx" is a male neutered domestic shorthair cat (6.74kg BSC 8/9) that was diagnosed with diabetes mellitus December 18th, 2012. He was started on M/D diet and 1.5 units of lantus insulin in December. His first curve his lowest blood sugar was 22.2. His insulin was increased to 2 units BID. His next curve done at home by the owner has the lowest blood sugar as 28.7 (January 31st). He was still PU/PD/Polyphagic at this point.
February 6, 2013 - lowest number on the curve is 25.4. Insulin increased to 3.5 units BID
February 18, 2013 - lowest number on the curve is 17.9. Insulin increased to 4 units BID
March 1, 2013 - owner complains that cat's feces are very smelly. Diet changed to diabetic.
March 13, 2013 - cat came in for a denta. Has gained 0.58kg! Wt now 7.32kg. Urine sample taken by cysto for culture came back negative. Reduced insulin to 2 units BID post dental. Diet plan started limiting food.
March 25, 2013 - lowest number on the curve is 30.0. Insulin increased to 3 units BID
April 9, 2013 - lowest number on curve is 27.2. A new bottle of insulin is started and insulin is increased to 3.5 units BID.
April 24 2013 - last curve is:
6:30am 33.4
6:35 am 3.5 units of insulin given
10am 29.0
12pm 27.3
2pm 28.6
Owner quit because she was frustrated
I have gone over and over handling of insulin with the owner. This cat continues to be unregulated despite increasing his insulin. Suggestions? | Or is my insulin dose just way too low for that heavy of a cat? | Did you leave masses in? |
Hello,
I have a case that is not going as well as I hoped and would appreciate a quick look.
This is a 9 1/2 y/o MN pug with a history of 2 seizures and PU/PD, we first saw him on April 18th. No previous history of seizures..or PU/PD.
Blood glucose was 484. BCS 4/5, moderately heavy tartar on teeth but no obviously infected teeth, otherwise PE is unremarkable.
UA=only got a couple of drops of urine but ketones ++, negative blood, glucose large, ph 7, no SG (sorry)
Here's his cbc/chem/T4 | What incredibly obvious thing am i missing here that will link the seizures, diabetes, and insulin resistance? | Urine culture is negative? |
Hello,
I have a case that is not going as well as I hoped and would appreciate a quick look.
This is a 9 1/2 y/o MN pug with a history of 2 seizures and PU/PD, we first saw him on April 18th. No previous history of seizures..or PU/PD.
Blood glucose was 484. BCS 4/5, moderately heavy tartar on teeth but no obviously infected teeth, otherwise PE is unremarkable.
UA=only got a couple of drops of urine but ketones ++, negative blood, glucose large, ph 7, no SG (sorry)
Here's his cbc/chem/T4 | What should our next step be? | Is she spayed? |
Hello,
I have a case that is not going as well as I hoped and would appreciate a quick look.
This is a 9 1/2 y/o MN pug with a history of 2 seizures and PU/PD, we first saw him on April 18th. No previous history of seizures..or PU/PD.
Blood glucose was 484. BCS 4/5, moderately heavy tartar on teeth but no obviously infected teeth, otherwise PE is unremarkable.
UA=only got a couple of drops of urine but ketones ++, negative blood, glucose large, ph 7, no SG (sorry)
Here's his cbc/chem/T4 | What's my best option for a client and patient like this? | Not sure exactly how you're giving 10 mg of azathioprine...it comes in a 50 mg tablet? |
Hello,
I have a case that is not going as well as I hoped and would appreciate a quick look.
This is a 9 1/2 y/o MN pug with a history of 2 seizures and PU/PD, we first saw him on April 18th. No previous history of seizures..or PU/PD.
Blood glucose was 484. BCS 4/5, moderately heavy tartar on teeth but no obviously infected teeth, otherwise PE is unremarkable.
UA=only got a couple of drops of urine but ketones ++, negative blood, glucose large, ph 7, no SG (sorry)
Here's his cbc/chem/T4 | Or...is w/d really the way to go if we want to optimize our chances? | How did the owner get going on giving the insulin 30 minutes after the meals? |
Tiffany is a diabetic, 11 yr old, 13 lb, spfe dsh that has been well controlled on 3 units of Lantus bid.
Fructosamine is 308 (142 - 450). Chem profile is normal except for glucose - 298, cholesterol - 260, and triglyceride - 215.
Recent urine culture was positive for E. coli which is sensitive to numerous antibiotics including Convenia which she will be on for 6 weeks followed by another culture.
Tiffany's diet was recently changed to canned Purina DM. She has an excellent appetite.
Tiffany has a prodigiously pendulous abdomen with very thin, flaky skin and localized areas of erythema and crusts. She also has billaterally symmetrical truncal and perineal alopecia, and no hair regrowth 2 months after being clipped for an ultrasound. Tiffany is obsessively thirsty for water.
LDDS results at the 0.1 mg/kg dexamethasone dose were: pre (hour 0) cortisol of 2.5 ( 1.8 - 3.7), and an 8 hour post cortisol of 1.0.
Abdominal u/s revealed a left adrenal width of 0.51cm left, and a right of 0.46cm.
So, could Tiffany still have Cushing's? Not sure how to proceed - any thoughts are appreciated, thanks! | Do you have a 4-hour-post result? | Neck palpated normal? |
Tiffany is a diabetic, 11 yr old, 13 lb, spfe dsh that has been well controlled on 3 units of Lantus bid.
Fructosamine is 308 (142 - 450). Chem profile is normal except for glucose - 298, cholesterol - 260, and triglyceride - 215.
Recent urine culture was positive for E. coli which is sensitive to numerous antibiotics including Convenia which she will be on for 6 weeks followed by another culture.
Tiffany's diet was recently changed to canned Purina DM. She has an excellent appetite.
Tiffany has a prodigiously pendulous abdomen with very thin, flaky skin and localized areas of erythema and crusts. She also has billaterally symmetrical truncal and perineal alopecia, and no hair regrowth 2 months after being clipped for an ultrasound. Tiffany is obsessively thirsty for water.
LDDS results at the 0.1 mg/kg dexamethasone dose were: pre (hour 0) cortisol of 2.5 ( 1.8 - 3.7), and an 8 hour post cortisol of 1.0.
Abdominal u/s revealed a left adrenal width of 0.51cm left, and a right of 0.46cm.
So, could Tiffany still have Cushing's? Not sure how to proceed - any thoughts are appreciated, thanks! | What is tiffany's bcs? | When you examined this kitty, were you able to palpate the dorsal spinous processes? |
Tiffany is a diabetic, 11 yr old, 13 lb, spfe dsh that has been well controlled on 3 units of Lantus bid.
Fructosamine is 308 (142 - 450). Chem profile is normal except for glucose - 298, cholesterol - 260, and triglyceride - 215.
Recent urine culture was positive for E. coli which is sensitive to numerous antibiotics including Convenia which she will be on for 6 weeks followed by another culture.
Tiffany's diet was recently changed to canned Purina DM. She has an excellent appetite.
Tiffany has a prodigiously pendulous abdomen with very thin, flaky skin and localized areas of erythema and crusts. She also has billaterally symmetrical truncal and perineal alopecia, and no hair regrowth 2 months after being clipped for an ultrasound. Tiffany is obsessively thirsty for water.
LDDS results at the 0.1 mg/kg dexamethasone dose were: pre (hour 0) cortisol of 2.5 ( 1.8 - 3.7), and an 8 hour post cortisol of 1.0.
Abdominal u/s revealed a left adrenal width of 0.51cm left, and a right of 0.46cm.
So, could Tiffany still have Cushing's? Not sure how to proceed - any thoughts are appreciated, thanks! | How's her weight been? | Is the cat polydipsic? |
Tiffany is a diabetic, 11 yr old, 13 lb, spfe dsh that has been well controlled on 3 units of Lantus bid.
Fructosamine is 308 (142 - 450). Chem profile is normal except for glucose - 298, cholesterol - 260, and triglyceride - 215.
Recent urine culture was positive for E. coli which is sensitive to numerous antibiotics including Convenia which she will be on for 6 weeks followed by another culture.
Tiffany's diet was recently changed to canned Purina DM. She has an excellent appetite.
Tiffany has a prodigiously pendulous abdomen with very thin, flaky skin and localized areas of erythema and crusts. She also has billaterally symmetrical truncal and perineal alopecia, and no hair regrowth 2 months after being clipped for an ultrasound. Tiffany is obsessively thirsty for water.
LDDS results at the 0.1 mg/kg dexamethasone dose were: pre (hour 0) cortisol of 2.5 ( 1.8 - 3.7), and an 8 hour post cortisol of 1.0.
Abdominal u/s revealed a left adrenal width of 0.51cm left, and a right of 0.46cm.
So, could Tiffany still have Cushing's? Not sure how to proceed - any thoughts are appreciated, thanks! | How's her usg? | Just the high sap? |
Tiffany is a diabetic, 11 yr old, 13 lb, spfe dsh that has been well controlled on 3 units of Lantus bid.
Fructosamine is 308 (142 - 450). Chem profile is normal except for glucose - 298, cholesterol - 260, and triglyceride - 215.
Recent urine culture was positive for E. coli which is sensitive to numerous antibiotics including Convenia which she will be on for 6 weeks followed by another culture.
Tiffany's diet was recently changed to canned Purina DM. She has an excellent appetite.
Tiffany has a prodigiously pendulous abdomen with very thin, flaky skin and localized areas of erythema and crusts. She also has billaterally symmetrical truncal and perineal alopecia, and no hair regrowth 2 months after being clipped for an ultrasound. Tiffany is obsessively thirsty for water.
LDDS results at the 0.1 mg/kg dexamethasone dose were: pre (hour 0) cortisol of 2.5 ( 1.8 - 3.7), and an 8 hour post cortisol of 1.0.
Abdominal u/s revealed a left adrenal width of 0.51cm left, and a right of 0.46cm.
So, could Tiffany still have Cushing's? Not sure how to proceed - any thoughts are appreciated, thanks! | Was there glucosuria? | How was she doing clinically on the nph at 4.5 units? |
Tiffany is a diabetic, 11 yr old, 13 lb, spfe dsh that has been well controlled on 3 units of Lantus bid.
Fructosamine is 308 (142 - 450). Chem profile is normal except for glucose - 298, cholesterol - 260, and triglyceride - 215.
Recent urine culture was positive for E. coli which is sensitive to numerous antibiotics including Convenia which she will be on for 6 weeks followed by another culture.
Tiffany's diet was recently changed to canned Purina DM. She has an excellent appetite.
Tiffany has a prodigiously pendulous abdomen with very thin, flaky skin and localized areas of erythema and crusts. She also has billaterally symmetrical truncal and perineal alopecia, and no hair regrowth 2 months after being clipped for an ultrasound. Tiffany is obsessively thirsty for water.
LDDS results at the 0.1 mg/kg dexamethasone dose were: pre (hour 0) cortisol of 2.5 ( 1.8 - 3.7), and an 8 hour post cortisol of 1.0.
Abdominal u/s revealed a left adrenal width of 0.51cm left, and a right of 0.46cm.
So, could Tiffany still have Cushing's? Not sure how to proceed - any thoughts are appreciated, thanks! | How long-standing has the skin problem been? | How likely is it to have cushing's with a concentrated usg and normal alp? |
Tiffany is a diabetic, 11 yr old, 13 lb, spfe dsh that has been well controlled on 3 units of Lantus bid.
Fructosamine is 308 (142 - 450). Chem profile is normal except for glucose - 298, cholesterol - 260, and triglyceride - 215.
Recent urine culture was positive for E. coli which is sensitive to numerous antibiotics including Convenia which she will be on for 6 weeks followed by another culture.
Tiffany's diet was recently changed to canned Purina DM. She has an excellent appetite.
Tiffany has a prodigiously pendulous abdomen with very thin, flaky skin and localized areas of erythema and crusts. She also has billaterally symmetrical truncal and perineal alopecia, and no hair regrowth 2 months after being clipped for an ultrasound. Tiffany is obsessively thirsty for water.
LDDS results at the 0.1 mg/kg dexamethasone dose were: pre (hour 0) cortisol of 2.5 ( 1.8 - 3.7), and an 8 hour post cortisol of 1.0.
Abdominal u/s revealed a left adrenal width of 0.51cm left, and a right of 0.46cm.
So, could Tiffany still have Cushing's? Not sure how to proceed - any thoughts are appreciated, thanks! | Any his of skin tears? | Have you tried doxycycline and piroxicam? |
Casey is a 15 yr old FS Bichon. She is very, very arthritic and eats canned j/d diet. The owner seems to be good about measuring her meals consistently. I diagnosed her with diabetes mellitus 2/11/13. See her initial labwork. She was initially started on 5 units bid of Humulin N. We have been using the AlphaTrak2 to monitor her BG's.
The owner is not compliant with blood glucose curves and refuses to drop Casey off for the day for us to accomplish that. We had been doing approximately 6 hr post insulin and pre-insulin blood sugars by appointment so far to monitor her. She took a couple weeks to really respond well with greatly diminished clinical signs. We gradually increased her to 8 units, checking BG every 7 to 10 days, but then the owner was concerned she had long drowsy periods of the afternoon when she though her glucose must have been low, although this suspicion could not be confirmed by a low reading that time of day.
2/11 insulin started
2/15 Owner concerned BG 605, went up to 7 units
2/18 343 preinsulin stay at 7 units 2/22 378 preinsulin on 7 units so went up to 8 units
3/1 do ok but acting like she is starving. BG preinsulin 99 so went down one unit back to 7 units. Ok'd increasing food by a few tablespoons.
3/8 12:40 pm 177 and 4:55 pm 131 and everything is great!
3/30 BG preinsulin 96 on 7 units bid and still great.
4/19 BG 600 preinsulin so went up to 8 units
4/26 BG 680 on 8 units
Based on a pre-insulin BG 96, I reduced her dose to 7 units. She was doing excellent so I had her return after a month this time only to find her pre-insulin BG was 600! I asked the owner if she changed anything with her technique, the bottle, etc. and she says she started injected in only one location that is comfortable for Casey. I watched her give injections at the initial consult but I have not set up a time to watch her give it again. I pably need to do this too.
I had her go up to 8 units again and return in one week. So now the BG pre-insulin is 680! She is a little more PU/PD and has lost a little weight again. She is still having the deep naps in the afternoon that scare her owner and at times she seems to not be able to wake her.
Assuming the owner is correctly administering the insulin, (Not sure I can assume but she started off doing a great job of it.) then do you think she could be experiencing Somogyi effect? Should I reduce her dose back to 6 units for at least a week and then curve her? (I may have the owner convinced now to let me do a curve.)
Or do you think she needs a dose increase? | Can they do curve at home? | We're absolutely sure she's spayed? |
I have a case that I have been reading up on, but I'm wanting some new eyes to look at and tell me if I'm missing anything or what my next step should be.
Tabby is a 12 year old neutered male DSH. He initially presented to me in March for chronic vomiting and diarrhea with some blood in the diarrhea. At that point, he appetite was occasionally picky, but generally he was eating and drinking. The vomiting was sometimes daily, but then he would go for stretches of 3-4 days with no vomiting. The diarrhea was basically constant, but would fluctuate between watery and pasty consistency. His diet consisted of a number of different grocery store brands of dry and wet cat food - nothing very consistent.
Initial exam was fairly unremarkable. Tabby was 16 lbs (BCS 7/9). He was bright and alert and more than willing to interact with me in the exam room. Abdomen was soft and non-painful, hydration status within normal limits. Fecal exam was negative (we do floats, not centrifugation, so I'm never sure if I can totally trust what I see). We performed CBC/chem, which was unremarkable. I placed him on panacur and albon, which the owners had trouble giving. He re-presented about 2 weeks later due to no improvement. It was only at this visit, that I learned that the owners had not been able to finish the albon, but since coccidiosis was not high on my list, I guess I did not contribute the lack of improvement necessarily to treatment failure. I questioned them a bit more at this visit and learned that Tabby gets worse on certain types of food. I recommended that we try feeding him ONE consistent diet. I sent them home with cans of Science Diet adult maintenance.
Two weeks later, Tabby is back. The vomiting improved for a few days on the Science Diet, but then returned, and then his appetite tanked. They switched up his diet in an effort to get him to eat, but the vomiting is now daily. Diarrhea is no longer bloody, but is not improved either. We repeated blood work including T4 and I recommended a cobalamine, folate, PLI, TLI profile, which they allowed me to perform. All values were within normal limits.
I spoke with them about finding a very consistent, highly digestible diet for Tabby to help us rule out sensitivity to one of his foods. We started him on i/d and cerenia to improve the vomiting. The cerenia stopped the vomiting, but Tabby was almost entirely inappetant. I started him on mirtazapine and the owner reported that it did increase his appetite for about 36 hours. But, once we got him eating again and the initial 3 days of cerenia wore off, he is back to vomiting and not eating.
Clearly the return of vomiting leads to Tabby not wanting to eat and we are not even able to get him eating regularly enough to see if the i/d will help at all. He has also lost weight, which has me concerned. I'm hesitant to try metaclopramide because in the midst of all of this, when Tabby does eat, he has diarrhea. I really think that biopsies may be the next step. I have been trying to broach this subject during the last few visits with the owner. I can either send them for referral for an endoscopy, or I would be willing to do an abdominal exploratory. My hesitation with that is that Tabby is already not wanting to eat, do I want to put him through invasive diagnostics? Hear are my three thoughts of where to go from here:
1. Survey rads of the abdomen. If I see evidence of ileus, we could try some metoclopramide. Again though, I don't want to make the diarrhea worse. If we still can't stop the vomiting, then I would perform an abdominal explore with biopsies of stomach and small intestine, mesenteric lymph nodes and possible pancreas and liver. This would hopefully give us a definitive diagnosis. At the same time, I have thought about placing an esophageal feeding tube to get nutrients into Tabby, then use cerenia to help keep him from vomiting while we are waiting for biopsy results.
2. Referral for endoscopy and ultrasound. This would be less invasive, but may not provide all the answers we need. I actually think that owners would go for either option 1 or 2. Despite not being able to stick to a diet well, they have been willing to do any tests that I have recommended.
3. Trial of oral steroids +/- metronidazole. I have discussed this possibility with the owner, but if it doesn't work, then we are back to square one and we still don't have a diagnosis.
Am I jumping to biopsies too quickly or would this be the logical next step at this point? Since the owners have been pretty good about following my diagnostic recommendations, I don't want to beat around the bush with many more medication trials if we eventually will be doing an abdominal explore anyway.
Is the feeding tube a good idea? I really just want to get nutrients into this cat. I've hit a wall with trying to get him to eat on his own.
Any other suggestions would be greatly appreciated. | Do you have a recent urinalysis? | I'm not quite following the timing of when he has to leave....but to me a 'swing shift' is something like 3 pm-11 pm...is that about right? |
Hi all,
Now that I have VIN, I'm going to become obnoxious!! Thanks in advance!
So, I am now seeing a 12 yo M/N obese (19#), indoor only cat. He has a history of chronic constipation. He was well controlled on lactulose, Miralax and metamucil. In March, he presented for diarrhea - on/off for one week. Owner had discontinued the Miralax and Lactulose because of the diarrhea. He only allows a minimal amount of handling. On abdominal palpation, there was a firm, approx 3 cm "mass" in his dorsocaudal abdomen. This "mass" was stool when seen on rads. FF was negative for ova (cat had recent history of fleas). I treated with metronidazole and forti-flora. He would not eat the fortiflora. Diarrhea did not resolve, but did improve to "pudding-like" stool just once a day. Since doing well, owner was happy. 2 weeks later, diarrhea started again. We started the cat on W/D. Once-a-day pudding stool continued. Cat also started vomiting once a day either food or phlegm/bile. So, today, I saw him back (approx 6 weeks from initial diarrhea appt). He has not lost any weight (still 19#) and looks ok on physical exam. I again felt a "mass" in his caudodorsal abdomen. It was firm to soft and non-painful. His small bowel felt normal, although his whole belly did feel a bit "doughy". We ran a panel of blood work (cbc,chem,lytes) - all was normal (BUN 29, Creat 1.4, glucose 148, ALT 117, ALKP 42, Ca 193). It's only been one week since starting the W/D and he is obese so I'm continuing that. I'm thinking there is a component of constipation since I'm feeling stool in his colon so I'm having her re-start the Miralax. Should I be starting cisapride? or pilocarpine? I've never used either one but we do have access to a compounding pharmacy where I can get cisapride. He is not a megacolon and I did not do a rectal (cat is borderline fractious).
This is my 3rd chronic diarrhea kitty in the past few months. The 2nd is doing well with added fiber and the 1st is getting there (he's a chronic IBD kitty that came to us from a different clinic and the owner isn't very compliant). Anyway, any help would be appreciated. Thanks!
☼ | Is there a history of chronic, intermittent vomiting of food, fluid and/or hair that precedes the current presentation? | Have you tried a prescription hypoallergenic diet? |
HI
I have 4 year old intact female beagle (last heat about 1 month ago) that presented with lethargy, and periodic anorexia & vomiting the past week (primarily small amounts of clear fluid at times) No history of vaginal drainage. May be increase in drinking. Overall, there has been a 7 pound weight loss the past 4 months, but owner also had her on a diet. Her weight now at 32 # looks good.
Bloodwork - white count 18,260 hi (occasional bands, no toxic granulation, mild neutrophilia.), hct 44.3%, platelets normal.
Chem - glucose 504(hi), bun/creat normal, total bili 1.1 (hi), chol 466 (hi) , amylase over 2,500 (hi), lipase 2626 (hi), sodium 142 sl low), K+ 3.6 normal, Cl 108 (low). normal: phos, cal, tp, alt, alkphos, ggt.
Spec cpli pending - should be back tomorrow.
Ultrasound screen of uterus - uterus does not appear to be enlarged.
working diagnosis - anorexic/ occasional vomiting dog with diabetes mellitus, possible pancreatitis. intact female.
She was admitted to the hospital, and started on iv fluids with antiemetics, and antibiotics. After a few hours on iv's, the glucose reading was 423, and she was started on a low dose of insulin.
I was wanting some input as regards to diabetes (pancreatitis?) in an intact female. If we get her turned around in the next day or so, would spaying her be warranted, and if so how will affect her as far as insulin requirements? (ie is it possible she won't need the insulin longterm?)
Thanks for any input on this case.
☼ | This is really a good time to teach the owner how to generate curves at home---any chance of that? | Have you done a rectal exam (would be cheaper than utlrasound if you feel a lesion)? |
Libby, an 8yr old FS miniature schnauzer, initially presented in Feb for limping that was found to be due to a toe nail problem. At that exam it was noted that she had severe dental disease, and being dental health month a dental was scheduled. Dog was not showing any signs of disease that the owner's had noted. Morning of the procedure, owner opts for the full array of pre-anesthetic testing we offer (bloodwork and EKG) as they previously had a pet die under anesthesia. Results are as follow:
Bloodwork unremarkable except ALT 113 (100), AlkP 1607 (212). EKG - axis deviation that could indicate cardiac disease and tall R waves that could indicate an enlarged left ventricle. Radiographs were obtained and I felt the liver seemed enlarged and the heart was also perhaps enlarged (I measured a VHS of 12). With a few abnormalities noted we cancelled the dental that day and sent the dog for a cardiology consult.
The results of the consult were: Chronic degenerative mitral valve disease, valve prolapsed in systole. The left heart measured high normal but this was felt not to be because of primary heart disease, but rather from severe systemic hypertension (systolic measured was 218). Splenomegaly and hepatomegaly were noted. The cardiologist started her on amlodipine.
Recheck with us using an oscillometric machine about a week after starting the meds - tech got 5 readings with SAP ranging from 142 to 163, DAP 56 - 117. Advised to continue amlodipine and consider further work-up (abdominal US to assess liver/adrenals had been recommended by the cardiologist).
Somehow follow-up fell through the cracks for a few months. Libby came in to see my colleague last Saturday because she had been drinking a lot more, having urine accidents in the house. She was eating normally but had lost 3# (bcs 3/9 from his notes). Repeat of an in-house chem 10 panel: AlkP 1129 (212), BUN 29 (27), Glucose 609 (143). Urine dipstick 2+ glucose. Started on 2U NPH insulin BID and wanted her in for Cushing's testing ASAP.
I returned from vacation yesterday and had her on my schedule for the testing (the colleague who saw her Saturday only works here 1 day a week). Owner had been planning on an LDDS but as I was refreshing my memory of that test and cruising VIN decided an ACTH stim might be better and switched to that (although at this point I'm kicking myself because I had gone back and forth on even testing in such a newly diagnosed diabetic). Owner was supposed to not feed in the am, probably didn't, but being a schnauzer my tech noted that the samples were lipemic. I will confess that we use the ACTH gel here (I've read the posts, not sure if I can convince the owner/manager to order anything else as the cost is a huge concern and my boss is overall happy with the results he gets from the gel) and the gel was nearing the expiration, so I erred on the higher side of the doses I could find for the gel. Pre was 2.4ug/dl, post 1.5ug/dl.
From what I've read, I can't fully rule-out Cushing's, but that testing her is going to be a challenge and she hasn't show clinical signs that I can say for certain are Cushing's (although we have tests that may be suggestive). I'm going to call the owner later today to go over the test results (test didn't show Cushing's but I can't say it isn't and possibly why I ran a different test than my colleague had talked to them about) and go over my thought process from here. 1) Work to get the diabetes regulated with glucose curves (owner will likely get frustrated quickly because they started on 0.25U/kg BID and from various sources including VIN I now start dogs at 0.5U/kg), but we'll see how it goes, and double check what diet they're on and see if I can switch them to low fat given the schnauzer lipemia thing, 2) get an abdominal US to look more closely at the liver/spleen and adrenal glands (can wait til we get insulin dose settled, or if we are getting up to the 2U/kg range without regulation) with possible aspirates, 3) consider a full UA and maybe a larger chem panel (so far we've only done in-house chem 10 and the dipstick was off the floor) as an adjunct to the US looking for our cause of the hypertension.
Anything else I'm missing? Thanks, ☼ | The boss really won't consider freezing left-over cortrosyn and passing the expense onto multiple patients and owners so one owner is not buying the whole vial? | Did you do a culture? |
Hello,
I have a diabetic 14 year old female spayed dachsund named Clover (9.2 lbs) who just wants to make me rip my hair out. She was diagnosed on February 26, 2013 with diabetes litus. (weight loss, pu/pd, ravenous appetite, acting normal otherwise)
Chem: Glu 545 mg/dl (70-143)
ALT 215 U/L (10-100)
AlKP 635 U/L (23-121)
Amyl 308 U/L (308-1500)
CBC: Normal
UA: Glu >2000; Ketone small-mod; SG: 1.034; Blood neg; pH 7.0
We started her on NPH insulin 2 units BID and Purina DCO food (owner feeding 1 1/8 cup of food per day split into 2 feedings)
We did a blood glucose curve in 7 days 3/7/13: (insulin given at 6:30 AM) 9.8 lbs--owner reports ravenous appetite, eating poop
8:45 69 mg/dl
9:45 65
10:45 81
11:45 80
12:45 80
2:45 86
Recommended double the dog's ration of food but keep the insulin dosage the same. Watch for signs of hypoglycemia
recheck glucose curve in 7 days unless signs of hypoglycemia noted
Next, Blood glucose curve 3/19/13: (insulin given 5:15 AM) 9.8 lbs owner thought possible hypoglycemia event last evening--seemed ataxic and disoriented so she gave karo syrup and she seemed fine. Owner still gave normal insulin dose without calling our office first in the AM. We advised to check with us first if this situation occurs again instead of giving insulin after a possible hypoglycemic event followed her blood glucose in house.
8:13 42
9:15 71
10:15 77
12:40 80
2:40 93
Recommended decrease insulin to 1 unit BID, increase food to 2 1/2 cups per day. Recheck curve in a week unless signs of hypoglycemia noted and owner should call when noted.
Next curve 3/26/13: (Insulin given 5:30 AM) o reports starting to not eat the DCO very well. Seems shaky before meals and owner noticing increased thirst. 9.6 lbs
7:35 25
8:35 41
9:35 29
10:35 59
11:35 37
12:35 39
1:55 50
2:55 77
Recommend no insulin and feed normally. Spot glucose check in 1 week unless pu/pd before that. If not eating DCO well switch to a food she will reliably eat.
Spot check glucose 4/2/13: 516 mg /dl 9.4 lbs
Recommended: feed regular diet so dog is eating very well and give 1/2 unit BID. Bring Clover in 3 days from starting insulin for a spot check 6 hrs after her insulin.
Spot check glucose 4/5/13: 429 mg/dl 9 lbs
Recommended a curve in 1 week
Glucose curve (o kept forgetting to bring in dog) 4/30/13: (insulin at 5:30)
7:30 50 mg/dl
8:30 47
9:30 71
11:30 85
Recommend no insulin.
Is this dog just highly sensitive to NPH insulin? Should I use oral meds instead of injectable insulin? Should I try 1/2 unit daily? Is there something else that I am missing here. During all these low sugar episodes the dog acts perfectly fine so I am sort of mystified.
Thanks for any light you can shed on this case for me,
☼ | I'd double check with the owner how he/she is measuring the insulin----right syringes? | Pulse oximetry? |
Hello,
I have a diabetic 14 year old female spayed dachsund named Clover (9.2 lbs) who just wants to make me rip my hair out. She was diagnosed on February 26, 2013 with diabetes litus. (weight loss, pu/pd, ravenous appetite, acting normal otherwise)
Chem: Glu 545 mg/dl (70-143)
ALT 215 U/L (10-100)
AlKP 635 U/L (23-121)
Amyl 308 U/L (308-1500)
CBC: Normal
UA: Glu >2000; Ketone small-mod; SG: 1.034; Blood neg; pH 7.0
We started her on NPH insulin 2 units BID and Purina DCO food (owner feeding 1 1/8 cup of food per day split into 2 feedings)
We did a blood glucose curve in 7 days 3/7/13: (insulin given at 6:30 AM) 9.8 lbs--owner reports ravenous appetite, eating poop
8:45 69 mg/dl
9:45 65
10:45 81
11:45 80
12:45 80
2:45 86
Recommended double the dog's ration of food but keep the insulin dosage the same. Watch for signs of hypoglycemia
recheck glucose curve in 7 days unless signs of hypoglycemia noted
Next, Blood glucose curve 3/19/13: (insulin given 5:15 AM) 9.8 lbs owner thought possible hypoglycemia event last evening--seemed ataxic and disoriented so she gave karo syrup and she seemed fine. Owner still gave normal insulin dose without calling our office first in the AM. We advised to check with us first if this situation occurs again instead of giving insulin after a possible hypoglycemic event followed her blood glucose in house.
8:13 42
9:15 71
10:15 77
12:40 80
2:40 93
Recommended decrease insulin to 1 unit BID, increase food to 2 1/2 cups per day. Recheck curve in a week unless signs of hypoglycemia noted and owner should call when noted.
Next curve 3/26/13: (Insulin given 5:30 AM) o reports starting to not eat the DCO very well. Seems shaky before meals and owner noticing increased thirst. 9.6 lbs
7:35 25
8:35 41
9:35 29
10:35 59
11:35 37
12:35 39
1:55 50
2:55 77
Recommend no insulin and feed normally. Spot glucose check in 1 week unless pu/pd before that. If not eating DCO well switch to a food she will reliably eat.
Spot check glucose 4/2/13: 516 mg /dl 9.4 lbs
Recommended: feed regular diet so dog is eating very well and give 1/2 unit BID. Bring Clover in 3 days from starting insulin for a spot check 6 hrs after her insulin.
Spot check glucose 4/5/13: 429 mg/dl 9 lbs
Recommended a curve in 1 week
Glucose curve (o kept forgetting to bring in dog) 4/30/13: (insulin at 5:30)
7:30 50 mg/dl
8:30 47
9:30 71
11:30 85
Recommend no insulin.
Is this dog just highly sensitive to NPH insulin? Should I use oral meds instead of injectable insulin? Should I try 1/2 unit daily? Is there something else that I am missing here. During all these low sugar episodes the dog acts perfectly fine so I am sort of mystified.
Thanks for any light you can shed on this case for me,
☼ | Measuring it accurately? | The owner is moving the injections around on her body each time? |
Hello
On April 12th I saw two kittens brought in for a health check. According to the owners they were told the kittens were 9 weeks old - but in my estimate they were max 6 weeks old. Both kittens had low grade diarrhoea at that point. Treated with fenbendazole and probiotics.
One week later (April 19) the male kitten came back. He had lost 120 g in a week, now had watery, bloody diarrhoea and was dehydrated. Admitted and treated with milbemycin, IV fluid therapy, IV Ceruoxime, B12, Metronidazole PO and Maropitant SC. At this point we took swaps for culture. PCV was 22. We did no more bloods as he was so weak and for our laboratory we need a lot of blood...
He perked up overnight, and was sent home after a couple of days on metronidazole PO, probiotics and a bland diet.
Presented again on the 23rd with blood in his faeces again, diarrhoea dribbling from him as he walked, anorectic.
Treated with fluids, antibiotic changed to clindamycin, given maropitant SC again. At this point we took a second sample and sent out for PCR testing.
On the 24th started him on loperamide as we reckoned that he had enough antibiotics that it should be safe to use. He perked up, seemed to do better.
Discontinued loperamide on the 27th
28th of April: Very watery diarrhoea again, otherwise bright, purring and playing. Started the loperamide again. Still on Clindamycin, bland diet and probiotics.
30th of April: Even on loperamide, watery diarrhoea many times a day - frank water around a puddle of what looks like undigested food. Now discontinuing antibiotics and just treating with probiotics.
Tests came back as:
Salmonella - culture and PCR negative
Campylobacter culture negative
Parasitology flotation negative
Tritrichomonas PCR negative
Toxoplasmosis PCR negative
Feline enteritis PCR negative
Giardia PCR negative
Cryptosporidium PCR negative
Clostridium perfringens enterotoxin PCR negative
Feline coronavirus PCR positive
Clostridium perfringens A gene PCR positive
SO - Jasper still has diarrhoea.... it looks as if he just isn't digesting his food. Am I missing out on something here? Is there anything else I can do? I have considered trying to add a bit of fibre to his food to slow down the transition time, and potentially after that giving him a novel protein diet to see if he will digest it better. At this point his sister weight 0.9kg. He weighs 0.68kg... He hasn't gained any weight in the last week.
Suggestions?
Thank you
Slightly frustrated here
☼ | Has jasper been tested for felv/fiv? | Do all these circumstance you are going through apply to all staff members equally? |
Hello
On April 12th I saw two kittens brought in for a health check. According to the owners they were told the kittens were 9 weeks old - but in my estimate they were max 6 weeks old. Both kittens had low grade diarrhoea at that point. Treated with fenbendazole and probiotics.
One week later (April 19) the male kitten came back. He had lost 120 g in a week, now had watery, bloody diarrhoea and was dehydrated. Admitted and treated with milbemycin, IV fluid therapy, IV Ceruoxime, B12, Metronidazole PO and Maropitant SC. At this point we took swaps for culture. PCV was 22. We did no more bloods as he was so weak and for our laboratory we need a lot of blood...
He perked up overnight, and was sent home after a couple of days on metronidazole PO, probiotics and a bland diet.
Presented again on the 23rd with blood in his faeces again, diarrhoea dribbling from him as he walked, anorectic.
Treated with fluids, antibiotic changed to clindamycin, given maropitant SC again. At this point we took a second sample and sent out for PCR testing.
On the 24th started him on loperamide as we reckoned that he had enough antibiotics that it should be safe to use. He perked up, seemed to do better.
Discontinued loperamide on the 27th
28th of April: Very watery diarrhoea again, otherwise bright, purring and playing. Started the loperamide again. Still on Clindamycin, bland diet and probiotics.
30th of April: Even on loperamide, watery diarrhoea many times a day - frank water around a puddle of what looks like undigested food. Now discontinuing antibiotics and just treating with probiotics.
Tests came back as:
Salmonella - culture and PCR negative
Campylobacter culture negative
Parasitology flotation negative
Tritrichomonas PCR negative
Toxoplasmosis PCR negative
Feline enteritis PCR negative
Giardia PCR negative
Cryptosporidium PCR negative
Clostridium perfringens enterotoxin PCR negative
Feline coronavirus PCR positive
Clostridium perfringens A gene PCR positive
SO - Jasper still has diarrhoea.... it looks as if he just isn't digesting his food. Am I missing out on something here? Is there anything else I can do? I have considered trying to add a bit of fibre to his food to slow down the transition time, and potentially after that giving him a novel protein diet to see if he will digest it better. At this point his sister weight 0.9kg. He weighs 0.68kg... He hasn't gained any weight in the last week.
Suggestions?
Thank you
Slightly frustrated here
☼ | What diet is he currently eating? | Wtf? |
Hello
On April 12th I saw two kittens brought in for a health check. According to the owners they were told the kittens were 9 weeks old - but in my estimate they were max 6 weeks old. Both kittens had low grade diarrhoea at that point. Treated with fenbendazole and probiotics.
One week later (April 19) the male kitten came back. He had lost 120 g in a week, now had watery, bloody diarrhoea and was dehydrated. Admitted and treated with milbemycin, IV fluid therapy, IV Ceruoxime, B12, Metronidazole PO and Maropitant SC. At this point we took swaps for culture. PCV was 22. We did no more bloods as he was so weak and for our laboratory we need a lot of blood...
He perked up overnight, and was sent home after a couple of days on metronidazole PO, probiotics and a bland diet.
Presented again on the 23rd with blood in his faeces again, diarrhoea dribbling from him as he walked, anorectic.
Treated with fluids, antibiotic changed to clindamycin, given maropitant SC again. At this point we took a second sample and sent out for PCR testing.
On the 24th started him on loperamide as we reckoned that he had enough antibiotics that it should be safe to use. He perked up, seemed to do better.
Discontinued loperamide on the 27th
28th of April: Very watery diarrhoea again, otherwise bright, purring and playing. Started the loperamide again. Still on Clindamycin, bland diet and probiotics.
30th of April: Even on loperamide, watery diarrhoea many times a day - frank water around a puddle of what looks like undigested food. Now discontinuing antibiotics and just treating with probiotics.
Tests came back as:
Salmonella - culture and PCR negative
Campylobacter culture negative
Parasitology flotation negative
Tritrichomonas PCR negative
Toxoplasmosis PCR negative
Feline enteritis PCR negative
Giardia PCR negative
Cryptosporidium PCR negative
Clostridium perfringens enterotoxin PCR negative
Feline coronavirus PCR positive
Clostridium perfringens A gene PCR positive
SO - Jasper still has diarrhoea.... it looks as if he just isn't digesting his food. Am I missing out on something here? Is there anything else I can do? I have considered trying to add a bit of fibre to his food to slow down the transition time, and potentially after that giving him a novel protein diet to see if he will digest it better. At this point his sister weight 0.9kg. He weighs 0.68kg... He hasn't gained any weight in the last week.
Suggestions?
Thank you
Slightly frustrated here
☼ | Have you checked a fecal cytology on jasper? | If female, is she spayed? |
Rocky is a domestic cat, male neutered, 8 years old. He does not got outside but lives with 2 other indoor cats. The latest one as been adopted 2 years ago: she was found on the street.
I met Rocky for the 1st time in February 2013 for suspicion of an upper respiratory infection and was treated with L-Lysine HCl. He did not improved and tests were performed. The diagnosis was DKA.
He was treated with Glargine (Lantus). He was followed once/week and every time we had to increase the amount of insulin. He received 6UI BID.
On April 26th he was admitted to the hospital because he was not doing well. The tests showed a high blood glucose and ketones in his urine. Also there was an increased of WBC and Neutrophiles. The K was low. A culture on the urine was negative.
He was hospitalized and treated with IV fluids, KCl, Ampicillin IV, humalog (short acting insulin) IV and Lantus SC. There were no more ketones in his urine, the WBC and Neutrophiles went back to normal. A 12 hours blood glucose curve (every hour from 8AM until 8PM) was done every day but it is very difficult to keep the blood glucose in an acceptable range. It's between 20 and 39 mmol/L (international units).
A test for FeLV/FIV as been done and he his positive for FeLV. The 2 other cats that live with him has been tested yesterday PM and we are waiting for the results today.
Today he is receiving 10 UI Lantus BID and 10 UI of humalog IV PRN. He eats well: Royal Canin Diabetic.
Although he is not tested 24 hours per day (the owner declined the referral to the ICU), I have not observed the Somogyi phenomenon. Is he resistant to the insulin because of FeLV virus, should I use a different insulin, am I missing the Somogyi phenomenon?
Please help
Thank you
Regards
☼ | Is the diet he's eating being given in strictly the canned version? | In fact, 2/84 cats=2.4% which is less than the expected prevalence in healthy cats so maybe bartonella has some sort of protective effect for diabetes? |
Rocky is a domestic cat, male neutered, 8 years old. He does not got outside but lives with 2 other indoor cats. The latest one as been adopted 2 years ago: she was found on the street.
I met Rocky for the 1st time in February 2013 for suspicion of an upper respiratory infection and was treated with L-Lysine HCl. He did not improved and tests were performed. The diagnosis was DKA.
He was treated with Glargine (Lantus). He was followed once/week and every time we had to increase the amount of insulin. He received 6UI BID.
On April 26th he was admitted to the hospital because he was not doing well. The tests showed a high blood glucose and ketones in his urine. Also there was an increased of WBC and Neutrophiles. The K was low. A culture on the urine was negative.
He was hospitalized and treated with IV fluids, KCl, Ampicillin IV, humalog (short acting insulin) IV and Lantus SC. There were no more ketones in his urine, the WBC and Neutrophiles went back to normal. A 12 hours blood glucose curve (every hour from 8AM until 8PM) was done every day but it is very difficult to keep the blood glucose in an acceptable range. It's between 20 and 39 mmol/L (international units).
A test for FeLV/FIV as been done and he his positive for FeLV. The 2 other cats that live with him has been tested yesterday PM and we are waiting for the results today.
Today he is receiving 10 UI Lantus BID and 10 UI of humalog IV PRN. He eats well: Royal Canin Diabetic.
Although he is not tested 24 hours per day (the owner declined the referral to the ICU), I have not observed the Somogyi phenomenon. Is he resistant to the insulin because of FeLV virus, should I use a different insulin, am I missing the Somogyi phenomenon?
Please help
Thank you
Regards
☼ | Is this diet 7% carbs on an me (metabolizeable energy) basis? | They can draw up the right volume of insulin in the right syringe? |
Rocky is a domestic cat, male neutered, 8 years old. He does not got outside but lives with 2 other indoor cats. The latest one as been adopted 2 years ago: she was found on the street.
I met Rocky for the 1st time in February 2013 for suspicion of an upper respiratory infection and was treated with L-Lysine HCl. He did not improved and tests were performed. The diagnosis was DKA.
He was treated with Glargine (Lantus). He was followed once/week and every time we had to increase the amount of insulin. He received 6UI BID.
On April 26th he was admitted to the hospital because he was not doing well. The tests showed a high blood glucose and ketones in his urine. Also there was an increased of WBC and Neutrophiles. The K was low. A culture on the urine was negative.
He was hospitalized and treated with IV fluids, KCl, Ampicillin IV, humalog (short acting insulin) IV and Lantus SC. There were no more ketones in his urine, the WBC and Neutrophiles went back to normal. A 12 hours blood glucose curve (every hour from 8AM until 8PM) was done every day but it is very difficult to keep the blood glucose in an acceptable range. It's between 20 and 39 mmol/L (international units).
A test for FeLV/FIV as been done and he his positive for FeLV. The 2 other cats that live with him has been tested yesterday PM and we are waiting for the results today.
Today he is receiving 10 UI Lantus BID and 10 UI of humalog IV PRN. He eats well: Royal Canin Diabetic.
Although he is not tested 24 hours per day (the owner declined the referral to the ICU), I have not observed the Somogyi phenomenon. Is he resistant to the insulin because of FeLV virus, should I use a different insulin, am I missing the Somogyi phenomenon?
Please help
Thank you
Regards
☼ | Is he obese? | Do you have a urine culture and lepto titers to round out the problem specific database for pupd? |
Rocky is a domestic cat, male neutered, 8 years old. He does not got outside but lives with 2 other indoor cats. The latest one as been adopted 2 years ago: she was found on the street.
I met Rocky for the 1st time in February 2013 for suspicion of an upper respiratory infection and was treated with L-Lysine HCl. He did not improved and tests were performed. The diagnosis was DKA.
He was treated with Glargine (Lantus). He was followed once/week and every time we had to increase the amount of insulin. He received 6UI BID.
On April 26th he was admitted to the hospital because he was not doing well. The tests showed a high blood glucose and ketones in his urine. Also there was an increased of WBC and Neutrophiles. The K was low. A culture on the urine was negative.
He was hospitalized and treated with IV fluids, KCl, Ampicillin IV, humalog (short acting insulin) IV and Lantus SC. There were no more ketones in his urine, the WBC and Neutrophiles went back to normal. A 12 hours blood glucose curve (every hour from 8AM until 8PM) was done every day but it is very difficult to keep the blood glucose in an acceptable range. It's between 20 and 39 mmol/L (international units).
A test for FeLV/FIV as been done and he his positive for FeLV. The 2 other cats that live with him has been tested yesterday PM and we are waiting for the results today.
Today he is receiving 10 UI Lantus BID and 10 UI of humalog IV PRN. He eats well: Royal Canin Diabetic.
Although he is not tested 24 hours per day (the owner declined the referral to the ICU), I have not observed the Somogyi phenomenon. Is he resistant to the insulin because of FeLV virus, should I use a different insulin, am I missing the Somogyi phenomenon?
Please help
Thank you
Regards
☼ | The owners can accurately measure and then inject the insulin? | Has the clinical image changed for the worse since stopping the thyroxine? |
Rocky is a domestic cat, male neutered, 8 years old. He does not got outside but lives with 2 other indoor cats. The latest one as been adopted 2 years ago: she was found on the street.
I met Rocky for the 1st time in February 2013 for suspicion of an upper respiratory infection and was treated with L-Lysine HCl. He did not improved and tests were performed. The diagnosis was DKA.
He was treated with Glargine (Lantus). He was followed once/week and every time we had to increase the amount of insulin. He received 6UI BID.
On April 26th he was admitted to the hospital because he was not doing well. The tests showed a high blood glucose and ketones in his urine. Also there was an increased of WBC and Neutrophiles. The K was low. A culture on the urine was negative.
He was hospitalized and treated with IV fluids, KCl, Ampicillin IV, humalog (short acting insulin) IV and Lantus SC. There were no more ketones in his urine, the WBC and Neutrophiles went back to normal. A 12 hours blood glucose curve (every hour from 8AM until 8PM) was done every day but it is very difficult to keep the blood glucose in an acceptable range. It's between 20 and 39 mmol/L (international units).
A test for FeLV/FIV as been done and he his positive for FeLV. The 2 other cats that live with him has been tested yesterday PM and we are waiting for the results today.
Today he is receiving 10 UI Lantus BID and 10 UI of humalog IV PRN. He eats well: Royal Canin Diabetic.
Although he is not tested 24 hours per day (the owner declined the referral to the ICU), I have not observed the Somogyi phenomenon. Is he resistant to the insulin because of FeLV virus, should I use a different insulin, am I missing the Somogyi phenomenon?
Please help
Thank you
Regards
☼ | How old is the current bottle of lantus? | Also, is there any issue with using serum from a diabetic dog? |
Rocky is a domestic cat, male neutered, 8 years old. He does not got outside but lives with 2 other indoor cats. The latest one as been adopted 2 years ago: she was found on the street.
I met Rocky for the 1st time in February 2013 for suspicion of an upper respiratory infection and was treated with L-Lysine HCl. He did not improved and tests were performed. The diagnosis was DKA.
He was treated with Glargine (Lantus). He was followed once/week and every time we had to increase the amount of insulin. He received 6UI BID.
On April 26th he was admitted to the hospital because he was not doing well. The tests showed a high blood glucose and ketones in his urine. Also there was an increased of WBC and Neutrophiles. The K was low. A culture on the urine was negative.
He was hospitalized and treated with IV fluids, KCl, Ampicillin IV, humalog (short acting insulin) IV and Lantus SC. There were no more ketones in his urine, the WBC and Neutrophiles went back to normal. A 12 hours blood glucose curve (every hour from 8AM until 8PM) was done every day but it is very difficult to keep the blood glucose in an acceptable range. It's between 20 and 39 mmol/L (international units).
A test for FeLV/FIV as been done and he his positive for FeLV. The 2 other cats that live with him has been tested yesterday PM and we are waiting for the results today.
Today he is receiving 10 UI Lantus BID and 10 UI of humalog IV PRN. He eats well: Royal Canin Diabetic.
Although he is not tested 24 hours per day (the owner declined the referral to the ICU), I have not observed the Somogyi phenomenon. Is he resistant to the insulin because of FeLV virus, should I use a different insulin, am I missing the Somogyi phenomenon?
Please help
Thank you
Regards
☼ | Is the owner moving the injections around on his body every day? | Is she supposed to be 100 pounds? |
Rocky is a domestic cat, male neutered, 8 years old. He does not got outside but lives with 2 other indoor cats. The latest one as been adopted 2 years ago: she was found on the street.
I met Rocky for the 1st time in February 2013 for suspicion of an upper respiratory infection and was treated with L-Lysine HCl. He did not improved and tests were performed. The diagnosis was DKA.
He was treated with Glargine (Lantus). He was followed once/week and every time we had to increase the amount of insulin. He received 6UI BID.
On April 26th he was admitted to the hospital because he was not doing well. The tests showed a high blood glucose and ketones in his urine. Also there was an increased of WBC and Neutrophiles. The K was low. A culture on the urine was negative.
He was hospitalized and treated with IV fluids, KCl, Ampicillin IV, humalog (short acting insulin) IV and Lantus SC. There were no more ketones in his urine, the WBC and Neutrophiles went back to normal. A 12 hours blood glucose curve (every hour from 8AM until 8PM) was done every day but it is very difficult to keep the blood glucose in an acceptable range. It's between 20 and 39 mmol/L (international units).
A test for FeLV/FIV as been done and he his positive for FeLV. The 2 other cats that live with him has been tested yesterday PM and we are waiting for the results today.
Today he is receiving 10 UI Lantus BID and 10 UI of humalog IV PRN. He eats well: Royal Canin Diabetic.
Although he is not tested 24 hours per day (the owner declined the referral to the ICU), I have not observed the Somogyi phenomenon. Is he resistant to the insulin because of FeLV virus, should I use a different insulin, am I missing the Somogyi phenomenon?
Please help
Thank you
Regards
☼ | Can i see some of his bg curves? | Cats can be fed throughout the day, but the total amount needs to be measured and reasonable for a cat this size...well, not 13#, as that sounds like he's obese? |
Any thoughts on a low dose dex results from a difficult diabetic cat. Dex dose was 0.1mg/kg
Pred dex 0.2 (1-6)
post 4hr dex 0.2
post 8hr dex 1.7 | Would you like to tell us the background story of what's going on so we can come up with a next step? | Why are you able to get only a small stream? |
Hello!
Junior is a 10 year old MN DSH who presented in January of 2012 with a several week history of diarrhea. Appetite was great, otherwise he seemed fine. Full bloodwork including T4 was normal and ova and parsites were negative. The owner felt he couldn't medicate him at home so we switched him to Medical Hypoallergenic diet. It is difficult to follow up with the owner since he is hard of hearing and has to come into the clinic rather than using the phone. He was treated for suspected allergies (facial pruritis) in 2011 (had another owner at this time) and responded well to dexamethasone tablets. He has not had recurrence of skin lesions. His stools at that point were reported to be normal. He is an indoor cat.
He presented again in April 2013 because his diarrhea never resolved on the hypoallergenic food (but he was adding in other foods too!). The owner also felt he is polyphagic, and pu/pd. Full bloodwork again was normal and urine SG was >1.050. T4 was at the lower end or normal. He described the stools as liquid but no blood, some mucous noted, but not voluminous. Junior had also lost 1 lb over the past year.
We started him on some metronidazole and after about 2 weeks his stools are better and have progressed to "cow patty" consistency but are not formed yet. I am concerned about IBD and discussed this with the owner but he has declined biopsies. I was thinking about doing a trial or prednisone but was hoping for an opinion on if there were other tests I should be running first. The owner was also asking me about budesonide. I have heard of this but never used it before. I contacted our compounding pharmacy and can get 1mg capsules. Is this a reasonalbe "first line" drug for suspected IBD or should I try some prednisone first. The owner of course is concerned about long term side effects.
Thank you!
☼ | Our compounding pharmacy has regular or sustained release capsules - is one preferrable over the other? | How many kcals/day is he eating? |
Squiggy is a 6 yr old m/n DSH cat that was seen for PU/PD on 3-14-13. He was 18.63#, obese, with a rough flaky dull coat, Stage 3 plus dental disease. His bladder was small but I managed to get a very small amount of urine which was positive on urine dipstick for glucose. Owner declined UA & c/s, CBC/Chem/T4; blood glucose was 408.
We tried him on the Royal Canin Diabetic formula, which he refused to eat.
I did explain to owner that if there were underlying problems he would be difficult to regulate, especially UTI etc, but she refused urine c/s, so I put him on Amoxidrops for 3 weeks. I started him on glargine 2 U SQ BID. He gets his injections at 5 am & 5 pm. She is currently feeding him the Friskies special diet formula (canned).
We got him in a week later (3-25-13)for glucose curve:
(Note: he would not eat the whole time he was here)
3 hr post insulin = 493
5 hr = 443
7 hr = 500
9 hr = 511
11 hr = 319
he got his pm insulin injection an hour later, then
1 hr = 542
I increased him to 3U BID. Glucose curve 4-5-13:
2 hrs post insulin = 322
4 hr = 308
6 hr = 369
8 hr = 347
10 hr = 392
12 hr = 433
When owner came to pick him up he was due for his insulin injection, so my technician observed how she was giving the insulin to confirm she was doing it correctly. His weight had dropped to 17.56#. She said he was drinking less, but still more than normal.
I increased his insulin dose to 4 U BID. Glucose curve 4-12-13:
2.5 hrs post insulin = 264
4.5 hrs = 387
6.5 hrs = 425
8.5 hrs = 350
10.5 hrs = 469
With the exception of 2.5 hrs post injection, his glucose levels were still pretty high, in fact seemed a bit higher, so I wondered about a Somogyi overswing. I reduced his insulin down to 1 U BID. Owner was upset about the cost of the glucose curves, so she brought in her glucometer and we compared, and she started doing the curves at home. This helped me at least find out his glucose level before his injection. When he was here on 4-19-13 his weight was down to 16.94#
Glucose curve (at home) 4-20-13 (Glargine 1 U SQ BID):
before inj = 437
2 hrs = 356
4 hrs = 466
6 hrs = 372
8 hrs = 439
10 hrs = 400
12 hrs = 398
I increased his dose to 1.5 U SQ BID; glucose curve at home on 4-24-13:
0 hrs = 420
2 hrs = 371
4 hrs = 394
6 hrs = 389
8 hrs =- 477
10 hrs = 445
12 hrs = 399
I rec'd con't 1.5 U SQ BID, recheck glucose curve at home on 5-1-13:
0 = 418
2 hrs = 429
4 hrs = 393
6 hrs = 381
8 hrs = 436
10 hrs = 424
12 hrs = 394
This cat does not seem to be responding to the insulin at any dose! I am not sure if he just needs higher insulin doses than 4 U, that seems like a large dose for glargine. I've never had to go higher than 2 1/2 Units!
I know he needs to have a full blood panel and urine culture/UA, but if owner won't do this, I'm not sure where to go from here.
Help?
Thanks in advance.
Barb
Waterford, MI
LSU SVM 1996 | Do you think the owner will let you do a dental? | Was cortrosyn used for the stim? |
Good morning!
Sophie is a 6 yo FS Bichon that I saw last week for frequent small urinations and licking at her vulva. She was not polydipsic and was otherwise normal in attitude and on PE. Owner feeds Royal Canine Weight diet and gives her Alpo Cheweeze as treats.
U/A (voided sample)
color - pale yellow
Clarity - clear
SG - 1.040
pH - 7.0
protein - trace
RBC - 4+ on stick and see
WBC - occ on sed
Glu - 500 mg/dL
Blood glucose - 6.3
I started Sophie on cephalexin and had the owner return in a few days with a fresh urine sample to rech for glucosuria and for a fasted blood sample.
Urine glucose - 500 mg/dL
UP/UC 0.52 (0.5)
Chem
ALB - 31 (25-44)
ALP - 20 (20-50) ***
ALT - 45 (10-118)
AMY - 788 (200-1200)
TBIL - 4 (2-10)
BUN - 9.2 (2.5-8.9) ***
CA - 2.44 (2.15-2.95)
PHOS - 1.89 (0.94-2.13)
CRE - 64 (27-124)
GLU - 6.5 (3.3-6.1) ***
NA+ - 143 (138-160)
K+ - 4.1 (3.7-5.8)
TP - 66 (54-82)
GLOB - 35 (23.52)
CBC
WBC - 9.0 (6-17) Rest WBC counts WNL's
RCB - 5.38 (5.5-8.5) ***
HGB - 12.5 (12-18)
HCT - 37.5 (37-55)
MCV - 70 (60.72
MCH - 23.2 (19.5-24.5)
MCHC - 33.3 (34-38 ***
RDW - 14.9 (12-16)
PLT - 521 (200-500) ***
MPV - 8.1 (6.1-10.1)
Her frequent urination symptoms had resolved.
So my question is, in light of an essentially normal chemistry and no clinical signs, should I pursue a dx of Fanconi's with venous blood gases and metabolic screening for aminoaciduria? Or should I just continue to monitor her blood and urine chemistry and urine?
With thanks,
☼ | Any potential exposure to jerky treats? | What about free t4 by ed and tsh? |
Good morning!
Sophie is a 6 yo FS Bichon that I saw last week for frequent small urinations and licking at her vulva. She was not polydipsic and was otherwise normal in attitude and on PE. Owner feeds Royal Canine Weight diet and gives her Alpo Cheweeze as treats.
U/A (voided sample)
color - pale yellow
Clarity - clear
SG - 1.040
pH - 7.0
protein - trace
RBC - 4+ on stick and see
WBC - occ on sed
Glu - 500 mg/dL
Blood glucose - 6.3
I started Sophie on cephalexin and had the owner return in a few days with a fresh urine sample to rech for glucosuria and for a fasted blood sample.
Urine glucose - 500 mg/dL
UP/UC 0.52 (0.5)
Chem
ALB - 31 (25-44)
ALP - 20 (20-50) ***
ALT - 45 (10-118)
AMY - 788 (200-1200)
TBIL - 4 (2-10)
BUN - 9.2 (2.5-8.9) ***
CA - 2.44 (2.15-2.95)
PHOS - 1.89 (0.94-2.13)
CRE - 64 (27-124)
GLU - 6.5 (3.3-6.1) ***
NA+ - 143 (138-160)
K+ - 4.1 (3.7-5.8)
TP - 66 (54-82)
GLOB - 35 (23.52)
CBC
WBC - 9.0 (6-17) Rest WBC counts WNL's
RCB - 5.38 (5.5-8.5) ***
HGB - 12.5 (12-18)
HCT - 37.5 (37-55)
MCV - 70 (60.72
MCH - 23.2 (19.5-24.5)
MCHC - 33.3 (34-38 ***
RDW - 14.9 (12-16)
PLT - 521 (200-500) ***
MPV - 8.1 (6.1-10.1)
Her frequent urination symptoms had resolved.
So my question is, in light of an essentially normal chemistry and no clinical signs, should I pursue a dx of Fanconi's with venous blood gases and metabolic screening for aminoaciduria? Or should I just continue to monitor her blood and urine chemistry and urine?
With thanks,
☼ | Not only chicken but now there are others? | Could he have another reason for the pu/pd? |
Good morning!
Sophie is a 6 yo FS Bichon that I saw last week for frequent small urinations and licking at her vulva. She was not polydipsic and was otherwise normal in attitude and on PE. Owner feeds Royal Canine Weight diet and gives her Alpo Cheweeze as treats.
U/A (voided sample)
color - pale yellow
Clarity - clear
SG - 1.040
pH - 7.0
protein - trace
RBC - 4+ on stick and see
WBC - occ on sed
Glu - 500 mg/dL
Blood glucose - 6.3
I started Sophie on cephalexin and had the owner return in a few days with a fresh urine sample to rech for glucosuria and for a fasted blood sample.
Urine glucose - 500 mg/dL
UP/UC 0.52 (0.5)
Chem
ALB - 31 (25-44)
ALP - 20 (20-50) ***
ALT - 45 (10-118)
AMY - 788 (200-1200)
TBIL - 4 (2-10)
BUN - 9.2 (2.5-8.9) ***
CA - 2.44 (2.15-2.95)
PHOS - 1.89 (0.94-2.13)
CRE - 64 (27-124)
GLU - 6.5 (3.3-6.1) ***
NA+ - 143 (138-160)
K+ - 4.1 (3.7-5.8)
TP - 66 (54-82)
GLOB - 35 (23.52)
CBC
WBC - 9.0 (6-17) Rest WBC counts WNL's
RCB - 5.38 (5.5-8.5) ***
HGB - 12.5 (12-18)
HCT - 37.5 (37-55)
MCV - 70 (60.72
MCH - 23.2 (19.5-24.5)
MCHC - 33.3 (34-38 ***
RDW - 14.9 (12-16)
PLT - 521 (200-500) ***
MPV - 8.1 (6.1-10.1)
Her frequent urination symptoms had resolved.
So my question is, in light of an essentially normal chemistry and no clinical signs, should I pursue a dx of Fanconi's with venous blood gases and metabolic screening for aminoaciduria? Or should I just continue to monitor her blood and urine chemistry and urine?
With thanks,
☼ | There also is a disease with primary glucosuria.....the blood sugar is also a little up...could this dog be becoming a diabetic? | Did you get a culture? |
Hi l - thanks in advance for the advice!
Lucy is a 17 yr FS DSH, indoor only with a history of CRD being treated with diet. Weight 12.5lbs. She originly presented 4/2/13 for PU/PD and urinating outside litter box. PE reveed a grade 1/6 murmur (historic HCM, not currently treated), otherwise fairly unremarkable. Blood pressure was elevated at 250mmHg. I sent out labs and results are below:
CBC:
WBC 9.5 (3.5-16.0)
RBC 8.7 (5.92-9.93)
HGB 12.4 (9.3-15.9)
HCT 38 (29-48)
MCV 43 (37-61)
MCH 14.3 (11-21)
MCHC 33 (30-38)
Platelet Count 486 (200-500)
Platelet Est Adequate
Differenti -Absolute
Neutrophils 6935 (2500-8500)
Bands 0 (0-150)
Lymphocytes 1805 (1200-8000)
Monocytes 190 (0-600)
Eosinophils 570 (0-1000)
Basophils 0 (0-150)
Absolute Metamyelocytes 0 (0-0)
Chem:
Tot Protein 8.1 (5.2-8.8)
bumin 3.7 (2.5-3.9)
Globulin 4.4 (2.3-5.3)
A/G Ratio 0.8 (0.35-1.5)
AST (SGOT) 24 (10-100)
ALT (SGPT) 65 (10-100)
k Phosphatase 31 (6-102)
GGT 1 (1-10)
Tot Bilirubin 0.1 (0.1-0.4)
Direct Bilirubin 0.0 (0.0-0.3)
Indirect Bilirubin 0.1 (0.0-0.3)
BUN 33 (14-36)
Creatinine 2.7 (HIGH) (0.6-2.4)
BUN/Creatinine Ratio 12 (4-33)
Phosphorus 3.6 (2.4-8.2)
Glucose 174 (HIGH) (64-170)
Ccium 13.5 (HIGH) (8.2-10.8)
Sodium 150 (145-158)
Potassium 5.0 (3.4-5.6)
Na/K Ratio 30 (LOW) (32-41)
Chloride 113 (104-128)
Bicarbonate 19 (12-30)
Anion Gap 23 (10-33)
Cholesterol 342 (HIGH) (75-220)
Amylase 1055 (100-1200)
Lipase 123 (0-205)
CPK 371(56-529)
Comment: Hemolysis 2+ No significant interference.
T4 2.1
UA:
Color Yellow
Appearance Cloudy
Specific Gravity 1.014 (LOW) (1.015-1.060)
pH 6.0 (5.5-7.0)
Protein Negative
Glucose-Strip Negative
Ketones Negative
Bilirubin Negative
Occult Blood Negative
WBC None
RBC None
Casts/LPF None Seen
Crysts None Seen
Bacteria None Seen
Epitheli Cells None Seen
Last labs were run 11/2012 Above abnorm vues at that time: Crea 1.9, glu 139, Ccium 10.9, USG 1.016
So discussed labs with owner - rule out CRD, idiopathic hypercciemia, neoplasia (Lymphoma). Recommended PTH/PTHrp/iCa but owner declined due to finances. Elected to start ccitriol and amlodipine, recheck labs. O so reported decreasing appetite so ok'd mirtazapine 1.875mg PO q72hr. Started ccitriol 53ng PO twice weekly and amlodipine 0.625mk PO daily -o actuly started both 4/10/13.
4/17/13 - BP check - 195mmHg.
Chem18:
Tot Protein 7.7 (5.2-8.8)
bumin 3.7 (2.5-3.9)
Globulin 4.0 (2.3-5.3)
A/G Ratio 0.9 (0.35-1.5)
ALT (SGPT) 140 (HIGH) (10-100)
k Phosphatase 44 (6-102)
GGT 1 (1-10)
Tot Bilirubin 0.1 (0.1-0.4)
BUN 39 (HIGH) (14-36)
Creatinine 3.0 (HIGH) (0.6-2.4)
Phosphorus 2.6 (2.4-8.2)
Glucose 126 (64-170)
Ccium 12.7 (HIGH) (8.2-10.8)
Sodium 148 (145-158)
Potassium 4.1 (3.4-5.6)
Chloride 109 (104-128)
Cholesterol 347 (HIGH) (75-220)
Amylase 1119 100-1200
So BUN/Crea slightly worse, Ca improved but not norm. ALT now elevated. O reports Lucy acted very high on 1/8th mirtazapine and felt appetite stimulating effects for 7 days. Due to this and elevated ALT, we reduced Mirtazapine dose to 0.9mg PO q 3-4 days (did compound in house to low for this low dose). Continued current ccitriol and amlodipine dose.
4/26/13: Chem18:
Tot Protein 7.6 (5.2-8.8)
bumin 3.7 (2.5-3.9)
Globulin 3.9 (2.3-5.3)
A/G Ratio 0.9 (0.35-1.5)
ALT (SGPT) 55 (10-100)
k Phosphatase 48 (6-102)
GGT 1 (1-10)
Tot Bilirubin 0.1 (0.1-0.4)
BUN 40 (HIGH) (14-36)
Creatinine 3.0 (HIGH) (0.6-2.4)
Phosphorus 2.8 (2.4-8.2)
Glucose 137 (64-170)
Ccium 12.8 (HIGH) (8.2-10.8)
Sodium 149 (145-158)
Potassium 4.1 (3.4-5.6)
Chloride 111 (104-128)
Cholesterol 355 (HIGH) (75-220)
Amylase 1131 (100-1200)
BUN/Crea/Ca stable, ALT now norm. O reports appetite still not great. Discussed again PTH profile vs imaging vs tri pred for idiopathic hyperccemia or neoplasia knowing risk for kidneys. O elects to try pred. Started prednisolone 5mg PO daily.
4/28 - received email from O - no change in appetite since starting pred, but owner is noting a clicking/grinding sound when eating that is progressively getting worse. Seems to bother patient - cause her to shake her head a little, not want to eat - see video below. so, one of the cats in household having V/D so my associate stopped the pred.
4/30 - recheck exam due to potenti V/D and jaw clicking: Weight down to 12.38lbs. PE shows mild tartar. Initily, grinding sound as 104 and 404 interdigitate. After manipulating jaw, no more grinding. No obvious pain on opening jaw but pt not thrilled with manuever. Rect exam showed norm stool (other cat in household has IBD and rect showed diarrhea so suspect not reacting to pred, but still unsure who is vomiting). Addition history - Pt had perio12/10/12 with whole mouth dent radiographs. At that time, 107 was extracted due to FORL, 301 and 302 extracted due to periodont disease. At this time my primary rule outs were TMJ myelitis/arthritis or rubber jaw. We did not do any addition treatment as pt ate well after jaw manipulation with no grinding noise.
5/1 - O reports grinding noise back, difficulty eating. My associate started buprenorphine 0.05ml (0.015mg) PO (low dose due to hypersensitivity to mirtazapine). Later that day, owner reported improvement in eating.
5/3 - Spoke with owner. Now not seeing as much effect with buprenorphine. I ok'd increasing to 0.01ml (0.03mg) buprenorphine for now.
Questions:
1) Is this more likely to be TMJ or RubberJaw?
2) Should we try gabapentin? Restart pred since not convinced vomiting was from this cat? Or is anesthesia with rads +/- surgery most appropriate?
Any other thoughts on rule/outs or potenti treatments is welcome! Sorry this is so long, but Lucy is a little complicated :)
☼ | Did you take tmj films at the time of the dent":"4b9bbc08-76b1-444f-9990-ec66c02d3e17","type":"diminutive_match"} treatment? | What's the current chem screen look like? |
Hi l - thanks in advance for the advice!
Lucy is a 17 yr FS DSH, indoor only with a history of CRD being treated with diet. Weight 12.5lbs. She originly presented 4/2/13 for PU/PD and urinating outside litter box. PE reveed a grade 1/6 murmur (historic HCM, not currently treated), otherwise fairly unremarkable. Blood pressure was elevated at 250mmHg. I sent out labs and results are below:
CBC:
WBC 9.5 (3.5-16.0)
RBC 8.7 (5.92-9.93)
HGB 12.4 (9.3-15.9)
HCT 38 (29-48)
MCV 43 (37-61)
MCH 14.3 (11-21)
MCHC 33 (30-38)
Platelet Count 486 (200-500)
Platelet Est Adequate
Differenti -Absolute
Neutrophils 6935 (2500-8500)
Bands 0 (0-150)
Lymphocytes 1805 (1200-8000)
Monocytes 190 (0-600)
Eosinophils 570 (0-1000)
Basophils 0 (0-150)
Absolute Metamyelocytes 0 (0-0)
Chem:
Tot Protein 8.1 (5.2-8.8)
bumin 3.7 (2.5-3.9)
Globulin 4.4 (2.3-5.3)
A/G Ratio 0.8 (0.35-1.5)
AST (SGOT) 24 (10-100)
ALT (SGPT) 65 (10-100)
k Phosphatase 31 (6-102)
GGT 1 (1-10)
Tot Bilirubin 0.1 (0.1-0.4)
Direct Bilirubin 0.0 (0.0-0.3)
Indirect Bilirubin 0.1 (0.0-0.3)
BUN 33 (14-36)
Creatinine 2.7 (HIGH) (0.6-2.4)
BUN/Creatinine Ratio 12 (4-33)
Phosphorus 3.6 (2.4-8.2)
Glucose 174 (HIGH) (64-170)
Ccium 13.5 (HIGH) (8.2-10.8)
Sodium 150 (145-158)
Potassium 5.0 (3.4-5.6)
Na/K Ratio 30 (LOW) (32-41)
Chloride 113 (104-128)
Bicarbonate 19 (12-30)
Anion Gap 23 (10-33)
Cholesterol 342 (HIGH) (75-220)
Amylase 1055 (100-1200)
Lipase 123 (0-205)
CPK 371(56-529)
Comment: Hemolysis 2+ No significant interference.
T4 2.1
UA:
Color Yellow
Appearance Cloudy
Specific Gravity 1.014 (LOW) (1.015-1.060)
pH 6.0 (5.5-7.0)
Protein Negative
Glucose-Strip Negative
Ketones Negative
Bilirubin Negative
Occult Blood Negative
WBC None
RBC None
Casts/LPF None Seen
Crysts None Seen
Bacteria None Seen
Epitheli Cells None Seen
Last labs were run 11/2012 Above abnorm vues at that time: Crea 1.9, glu 139, Ccium 10.9, USG 1.016
So discussed labs with owner - rule out CRD, idiopathic hypercciemia, neoplasia (Lymphoma). Recommended PTH/PTHrp/iCa but owner declined due to finances. Elected to start ccitriol and amlodipine, recheck labs. O so reported decreasing appetite so ok'd mirtazapine 1.875mg PO q72hr. Started ccitriol 53ng PO twice weekly and amlodipine 0.625mk PO daily -o actuly started both 4/10/13.
4/17/13 - BP check - 195mmHg.
Chem18:
Tot Protein 7.7 (5.2-8.8)
bumin 3.7 (2.5-3.9)
Globulin 4.0 (2.3-5.3)
A/G Ratio 0.9 (0.35-1.5)
ALT (SGPT) 140 (HIGH) (10-100)
k Phosphatase 44 (6-102)
GGT 1 (1-10)
Tot Bilirubin 0.1 (0.1-0.4)
BUN 39 (HIGH) (14-36)
Creatinine 3.0 (HIGH) (0.6-2.4)
Phosphorus 2.6 (2.4-8.2)
Glucose 126 (64-170)
Ccium 12.7 (HIGH) (8.2-10.8)
Sodium 148 (145-158)
Potassium 4.1 (3.4-5.6)
Chloride 109 (104-128)
Cholesterol 347 (HIGH) (75-220)
Amylase 1119 100-1200
So BUN/Crea slightly worse, Ca improved but not norm. ALT now elevated. O reports Lucy acted very high on 1/8th mirtazapine and felt appetite stimulating effects for 7 days. Due to this and elevated ALT, we reduced Mirtazapine dose to 0.9mg PO q 3-4 days (did compound in house to low for this low dose). Continued current ccitriol and amlodipine dose.
4/26/13: Chem18:
Tot Protein 7.6 (5.2-8.8)
bumin 3.7 (2.5-3.9)
Globulin 3.9 (2.3-5.3)
A/G Ratio 0.9 (0.35-1.5)
ALT (SGPT) 55 (10-100)
k Phosphatase 48 (6-102)
GGT 1 (1-10)
Tot Bilirubin 0.1 (0.1-0.4)
BUN 40 (HIGH) (14-36)
Creatinine 3.0 (HIGH) (0.6-2.4)
Phosphorus 2.8 (2.4-8.2)
Glucose 137 (64-170)
Ccium 12.8 (HIGH) (8.2-10.8)
Sodium 149 (145-158)
Potassium 4.1 (3.4-5.6)
Chloride 111 (104-128)
Cholesterol 355 (HIGH) (75-220)
Amylase 1131 (100-1200)
BUN/Crea/Ca stable, ALT now norm. O reports appetite still not great. Discussed again PTH profile vs imaging vs tri pred for idiopathic hyperccemia or neoplasia knowing risk for kidneys. O elects to try pred. Started prednisolone 5mg PO daily.
4/28 - received email from O - no change in appetite since starting pred, but owner is noting a clicking/grinding sound when eating that is progressively getting worse. Seems to bother patient - cause her to shake her head a little, not want to eat - see video below. so, one of the cats in household having V/D so my associate stopped the pred.
4/30 - recheck exam due to potenti V/D and jaw clicking: Weight down to 12.38lbs. PE shows mild tartar. Initily, grinding sound as 104 and 404 interdigitate. After manipulating jaw, no more grinding. No obvious pain on opening jaw but pt not thrilled with manuever. Rect exam showed norm stool (other cat in household has IBD and rect showed diarrhea so suspect not reacting to pred, but still unsure who is vomiting). Addition history - Pt had perio12/10/12 with whole mouth dent radiographs. At that time, 107 was extracted due to FORL, 301 and 302 extracted due to periodont disease. At this time my primary rule outs were TMJ myelitis/arthritis or rubber jaw. We did not do any addition treatment as pt ate well after jaw manipulation with no grinding noise.
5/1 - O reports grinding noise back, difficulty eating. My associate started buprenorphine 0.05ml (0.015mg) PO (low dose due to hypersensitivity to mirtazapine). Later that day, owner reported improvement in eating.
5/3 - Spoke with owner. Now not seeing as much effect with buprenorphine. I ok'd increasing to 0.01ml (0.03mg) buprenorphine for now.
Questions:
1) Is this more likely to be TMJ or RubberJaw?
2) Should we try gabapentin? Restart pred since not convinced vomiting was from this cat? Or is anesthesia with rads +/- surgery most appropriate?
Any other thoughts on rule/outs or potenti treatments is welcome! Sorry this is so long, but Lucy is a little complicated :)
☼ | Can you post any rads from that visit? | What is your normal range for that? |
Hello,
I have a puzzling case that I haven't been able to put all the various pieces together yet. I was hoping to tap into the collective brilliance of VIN.
We were presented with an acutely ill 3 year old pitbull. He was initially seen at a local clinic and then sent down to our emergency hospital, seen by a colleague and then transferred to me about 1 hour later for overnight care. The dog was initially ambulatory but came into our clinic non-ambulatory and I first saw him only after he had been given analgesia and sedation so I have never seen him un-sedated. I've written a summary of the information from the referring vet and what we've seen so far.
Leo seemed fine earlier today. He was with owner and very active, playing at local lake - not seen to have got into anything but was off leash and out of sight in bushes several times
Started to act odd, weak, looked gray, piloerection noted at some point along back.
Brought to local clinic and looked shocky, hypothermic (34.7oC, normal is 38.0-39oC) treated with IVF, seemed hunched and seemed unable to use RHL.
Frayed bloody nail on 5th digit RHL
Given analgesia (butorphanol)
Lateral rads taken at referring clinic showed aerophagia, poss FB in stomach (could be piece of rubber toy he was chewing last week). Some patchy mottling of mid to caudal lung fields (still need orthogonal views to assess further)
Came in to our clinic non-ambulatory, still hypothermic but improving,
Less shocky after IVF support, vitals improved, pink MM, temp normalized, HR and BP OK to increased
Started to vocalize and seem mentally altered
HR 120, BP 150
Hypoglycemic (1.9 mmol/L, normal is 4.11-7.95)
Given dextrose IV, K+ added to IVF, butorphanol repeated
Continued to vocalize loudly and be agitated, given alfaxolone IV which worked but didn't last long.
Seemed painful with palpation of RHL even while sedate.
Some dermatitis over legs and ventral body - these areas seemed to get more hyperemic between 18:30 and 19:30 (90 minutes of presentation to our clinic). According to owners he is prone to this, very reactive to many things, usually responds to anti-histamine and a steroid cream.
Bull's eye lesion found near right axilla (owner saw Leo yelp yesterday and has noticed wasps and thinks he might have been stung) - prone to allergic skin reactions, hives, rash.
LABWORK
CBC
WBC 11,300 ; lymphopenia (560)
Manual Hct 51%
PP 5.4
CHEM
Ca++ slt decr 1.92 (N=1.98-3.00 mmol/L)
Liver and renal values normal
TP low normal @ 52
Na+ decr @ 127 (N=144-160 mmol/L)
K+ decr @ 3.0 (N=3.5-5.8 mmol/L)
Cl low @ 99 (N= 109-122)
UA
USG 1.016 (sample collected in our hospital after he received IVF at referring clinic)
pH 8.0
sediment benign
no glucose or protein in urine
iSTAT
pH 7.406
HCO3 22.6
pCO2 36.0
Lytes also low on iSTAT
urea 3.57 (normal)
gluc was 1.925 (N= 4.11-7.95 mmol/L)
BE -2
Labwork shows normal pH with normal HCO3 and pCO2. All lytes below normal.
Lymphopenia
Ca++ slt low
USG 1.016
Repeated iSTAT 4.5 hours after admit; showed normal Na+ and Cl- with K+ just slightly below normal. Glucose normal. pH still normal.
**Has been producing lg amounts urine since admitted (~1750 mls in 5.5 hours = 10 ml/kg/hr 5-10x normal rate) - we have a urinary catheter in.
Continues to start to vocalize when not sedated on CRI meds - less vocal but whining and restless, stumbling - he is possibly less painful now (if he even was painful) but hard to assess due to altered consciousness (and I have never seen him pre-sedation/analgesia)
ASSESSMENT
Acuteness of onset suggest toxin - not many things cause hypoglycemia. Aside from medical issues such as insulinoma and severe hepatic disease (for both of which there is no history suggestive of these, no liver abn on labwork so far) - hypoglycemia not commonly seen with trauma, nor allergic reactions. Xylitol could cause hypoglycemia, diabetic meds (ie: oral anti-hyperglycemics) could cause. Not really anything else. No history of any of these but was off leash.
Allergic reaction could be a coincidental issue?
RHL lameness could be a secondary injury if Leo stumbled and hurt himself once he started being weak?
I'm not sure what is causing the polyuria. He may have received a large amount of fluids at the referring clinic but he was not there that long.
He is being maintained on a CRI of dexdomitor which is keeping him sleeping. Without it he is vocalizing and stumbling all over, agitated. Because he seemed painful at referring clinic and on palpation of RHL we have him on a fentanyl CRI as well. We are slowly tapering both down. When we tapered the DDM CRI too fast he woke up, initially was quiet and alert in sternal but then started to vocalize and stumble and fall around, wouldn't settle. We are planning on doing the orthogonal views of the thorax and the abdomen (VD views).
Does anyone have any brilliant ideas to pull all these things together, any suggestions for further workup or treatment?
☼ | Was he actually playing "in" the lake and gulping water? | Is the dog eating a reasonable amount? |
Hello,
I have a puzzling case that I haven't been able to put all the various pieces together yet. I was hoping to tap into the collective brilliance of VIN.
We were presented with an acutely ill 3 year old pitbull. He was initially seen at a local clinic and then sent down to our emergency hospital, seen by a colleague and then transferred to me about 1 hour later for overnight care. The dog was initially ambulatory but came into our clinic non-ambulatory and I first saw him only after he had been given analgesia and sedation so I have never seen him un-sedated. I've written a summary of the information from the referring vet and what we've seen so far.
Leo seemed fine earlier today. He was with owner and very active, playing at local lake - not seen to have got into anything but was off leash and out of sight in bushes several times
Started to act odd, weak, looked gray, piloerection noted at some point along back.
Brought to local clinic and looked shocky, hypothermic (34.7oC, normal is 38.0-39oC) treated with IVF, seemed hunched and seemed unable to use RHL.
Frayed bloody nail on 5th digit RHL
Given analgesia (butorphanol)
Lateral rads taken at referring clinic showed aerophagia, poss FB in stomach (could be piece of rubber toy he was chewing last week). Some patchy mottling of mid to caudal lung fields (still need orthogonal views to assess further)
Came in to our clinic non-ambulatory, still hypothermic but improving,
Less shocky after IVF support, vitals improved, pink MM, temp normalized, HR and BP OK to increased
Started to vocalize and seem mentally altered
HR 120, BP 150
Hypoglycemic (1.9 mmol/L, normal is 4.11-7.95)
Given dextrose IV, K+ added to IVF, butorphanol repeated
Continued to vocalize loudly and be agitated, given alfaxolone IV which worked but didn't last long.
Seemed painful with palpation of RHL even while sedate.
Some dermatitis over legs and ventral body - these areas seemed to get more hyperemic between 18:30 and 19:30 (90 minutes of presentation to our clinic). According to owners he is prone to this, very reactive to many things, usually responds to anti-histamine and a steroid cream.
Bull's eye lesion found near right axilla (owner saw Leo yelp yesterday and has noticed wasps and thinks he might have been stung) - prone to allergic skin reactions, hives, rash.
LABWORK
CBC
WBC 11,300 ; lymphopenia (560)
Manual Hct 51%
PP 5.4
CHEM
Ca++ slt decr 1.92 (N=1.98-3.00 mmol/L)
Liver and renal values normal
TP low normal @ 52
Na+ decr @ 127 (N=144-160 mmol/L)
K+ decr @ 3.0 (N=3.5-5.8 mmol/L)
Cl low @ 99 (N= 109-122)
UA
USG 1.016 (sample collected in our hospital after he received IVF at referring clinic)
pH 8.0
sediment benign
no glucose or protein in urine
iSTAT
pH 7.406
HCO3 22.6
pCO2 36.0
Lytes also low on iSTAT
urea 3.57 (normal)
gluc was 1.925 (N= 4.11-7.95 mmol/L)
BE -2
Labwork shows normal pH with normal HCO3 and pCO2. All lytes below normal.
Lymphopenia
Ca++ slt low
USG 1.016
Repeated iSTAT 4.5 hours after admit; showed normal Na+ and Cl- with K+ just slightly below normal. Glucose normal. pH still normal.
**Has been producing lg amounts urine since admitted (~1750 mls in 5.5 hours = 10 ml/kg/hr 5-10x normal rate) - we have a urinary catheter in.
Continues to start to vocalize when not sedated on CRI meds - less vocal but whining and restless, stumbling - he is possibly less painful now (if he even was painful) but hard to assess due to altered consciousness (and I have never seen him pre-sedation/analgesia)
ASSESSMENT
Acuteness of onset suggest toxin - not many things cause hypoglycemia. Aside from medical issues such as insulinoma and severe hepatic disease (for both of which there is no history suggestive of these, no liver abn on labwork so far) - hypoglycemia not commonly seen with trauma, nor allergic reactions. Xylitol could cause hypoglycemia, diabetic meds (ie: oral anti-hyperglycemics) could cause. Not really anything else. No history of any of these but was off leash.
Allergic reaction could be a coincidental issue?
RHL lameness could be a secondary injury if Leo stumbled and hurt himself once he started being weak?
I'm not sure what is causing the polyuria. He may have received a large amount of fluids at the referring clinic but he was not there that long.
He is being maintained on a CRI of dexdomitor which is keeping him sleeping. Without it he is vocalizing and stumbling all over, agitated. Because he seemed painful at referring clinic and on palpation of RHL we have him on a fentanyl CRI as well. We are slowly tapering both down. When we tapered the DDM CRI too fast he woke up, initially was quiet and alert in sternal but then started to vocalize and stumble and fall around, wouldn't settle. We are planning on doing the orthogonal views of the thorax and the abdomen (VD views).
Does anyone have any brilliant ideas to pull all these things together, any suggestions for further workup or treatment?
☼ | Retinal exam? | How did the last stim look? |
Hello,
I have a puzzling case that I haven't been able to put all the various pieces together yet. I was hoping to tap into the collective brilliance of VIN.
We were presented with an acutely ill 3 year old pitbull. He was initially seen at a local clinic and then sent down to our emergency hospital, seen by a colleague and then transferred to me about 1 hour later for overnight care. The dog was initially ambulatory but came into our clinic non-ambulatory and I first saw him only after he had been given analgesia and sedation so I have never seen him un-sedated. I've written a summary of the information from the referring vet and what we've seen so far.
Leo seemed fine earlier today. He was with owner and very active, playing at local lake - not seen to have got into anything but was off leash and out of sight in bushes several times
Started to act odd, weak, looked gray, piloerection noted at some point along back.
Brought to local clinic and looked shocky, hypothermic (34.7oC, normal is 38.0-39oC) treated with IVF, seemed hunched and seemed unable to use RHL.
Frayed bloody nail on 5th digit RHL
Given analgesia (butorphanol)
Lateral rads taken at referring clinic showed aerophagia, poss FB in stomach (could be piece of rubber toy he was chewing last week). Some patchy mottling of mid to caudal lung fields (still need orthogonal views to assess further)
Came in to our clinic non-ambulatory, still hypothermic but improving,
Less shocky after IVF support, vitals improved, pink MM, temp normalized, HR and BP OK to increased
Started to vocalize and seem mentally altered
HR 120, BP 150
Hypoglycemic (1.9 mmol/L, normal is 4.11-7.95)
Given dextrose IV, K+ added to IVF, butorphanol repeated
Continued to vocalize loudly and be agitated, given alfaxolone IV which worked but didn't last long.
Seemed painful with palpation of RHL even while sedate.
Some dermatitis over legs and ventral body - these areas seemed to get more hyperemic between 18:30 and 19:30 (90 minutes of presentation to our clinic). According to owners he is prone to this, very reactive to many things, usually responds to anti-histamine and a steroid cream.
Bull's eye lesion found near right axilla (owner saw Leo yelp yesterday and has noticed wasps and thinks he might have been stung) - prone to allergic skin reactions, hives, rash.
LABWORK
CBC
WBC 11,300 ; lymphopenia (560)
Manual Hct 51%
PP 5.4
CHEM
Ca++ slt decr 1.92 (N=1.98-3.00 mmol/L)
Liver and renal values normal
TP low normal @ 52
Na+ decr @ 127 (N=144-160 mmol/L)
K+ decr @ 3.0 (N=3.5-5.8 mmol/L)
Cl low @ 99 (N= 109-122)
UA
USG 1.016 (sample collected in our hospital after he received IVF at referring clinic)
pH 8.0
sediment benign
no glucose or protein in urine
iSTAT
pH 7.406
HCO3 22.6
pCO2 36.0
Lytes also low on iSTAT
urea 3.57 (normal)
gluc was 1.925 (N= 4.11-7.95 mmol/L)
BE -2
Labwork shows normal pH with normal HCO3 and pCO2. All lytes below normal.
Lymphopenia
Ca++ slt low
USG 1.016
Repeated iSTAT 4.5 hours after admit; showed normal Na+ and Cl- with K+ just slightly below normal. Glucose normal. pH still normal.
**Has been producing lg amounts urine since admitted (~1750 mls in 5.5 hours = 10 ml/kg/hr 5-10x normal rate) - we have a urinary catheter in.
Continues to start to vocalize when not sedated on CRI meds - less vocal but whining and restless, stumbling - he is possibly less painful now (if he even was painful) but hard to assess due to altered consciousness (and I have never seen him pre-sedation/analgesia)
ASSESSMENT
Acuteness of onset suggest toxin - not many things cause hypoglycemia. Aside from medical issues such as insulinoma and severe hepatic disease (for both of which there is no history suggestive of these, no liver abn on labwork so far) - hypoglycemia not commonly seen with trauma, nor allergic reactions. Xylitol could cause hypoglycemia, diabetic meds (ie: oral anti-hyperglycemics) could cause. Not really anything else. No history of any of these but was off leash.
Allergic reaction could be a coincidental issue?
RHL lameness could be a secondary injury if Leo stumbled and hurt himself once he started being weak?
I'm not sure what is causing the polyuria. He may have received a large amount of fluids at the referring clinic but he was not there that long.
He is being maintained on a CRI of dexdomitor which is keeping him sleeping. Without it he is vocalizing and stumbling all over, agitated. Because he seemed painful at referring clinic and on palpation of RHL we have him on a fentanyl CRI as well. We are slowly tapering both down. When we tapered the DDM CRI too fast he woke up, initially was quiet and alert in sternal but then started to vocalize and stumble and fall around, wouldn't settle. We are planning on doing the orthogonal views of the thorax and the abdomen (VD views).
Does anyone have any brilliant ideas to pull all these things together, any suggestions for further workup or treatment?
☼ | Did he appear dysphoric or potentially blind? | Did you run a cobalamin/folate/fpli/tli on this patient? |
Hello,
I have a puzzling case that I haven't been able to put all the various pieces together yet. I was hoping to tap into the collective brilliance of VIN.
We were presented with an acutely ill 3 year old pitbull. He was initially seen at a local clinic and then sent down to our emergency hospital, seen by a colleague and then transferred to me about 1 hour later for overnight care. The dog was initially ambulatory but came into our clinic non-ambulatory and I first saw him only after he had been given analgesia and sedation so I have never seen him un-sedated. I've written a summary of the information from the referring vet and what we've seen so far.
Leo seemed fine earlier today. He was with owner and very active, playing at local lake - not seen to have got into anything but was off leash and out of sight in bushes several times
Started to act odd, weak, looked gray, piloerection noted at some point along back.
Brought to local clinic and looked shocky, hypothermic (34.7oC, normal is 38.0-39oC) treated with IVF, seemed hunched and seemed unable to use RHL.
Frayed bloody nail on 5th digit RHL
Given analgesia (butorphanol)
Lateral rads taken at referring clinic showed aerophagia, poss FB in stomach (could be piece of rubber toy he was chewing last week). Some patchy mottling of mid to caudal lung fields (still need orthogonal views to assess further)
Came in to our clinic non-ambulatory, still hypothermic but improving,
Less shocky after IVF support, vitals improved, pink MM, temp normalized, HR and BP OK to increased
Started to vocalize and seem mentally altered
HR 120, BP 150
Hypoglycemic (1.9 mmol/L, normal is 4.11-7.95)
Given dextrose IV, K+ added to IVF, butorphanol repeated
Continued to vocalize loudly and be agitated, given alfaxolone IV which worked but didn't last long.
Seemed painful with palpation of RHL even while sedate.
Some dermatitis over legs and ventral body - these areas seemed to get more hyperemic between 18:30 and 19:30 (90 minutes of presentation to our clinic). According to owners he is prone to this, very reactive to many things, usually responds to anti-histamine and a steroid cream.
Bull's eye lesion found near right axilla (owner saw Leo yelp yesterday and has noticed wasps and thinks he might have been stung) - prone to allergic skin reactions, hives, rash.
LABWORK
CBC
WBC 11,300 ; lymphopenia (560)
Manual Hct 51%
PP 5.4
CHEM
Ca++ slt decr 1.92 (N=1.98-3.00 mmol/L)
Liver and renal values normal
TP low normal @ 52
Na+ decr @ 127 (N=144-160 mmol/L)
K+ decr @ 3.0 (N=3.5-5.8 mmol/L)
Cl low @ 99 (N= 109-122)
UA
USG 1.016 (sample collected in our hospital after he received IVF at referring clinic)
pH 8.0
sediment benign
no glucose or protein in urine
iSTAT
pH 7.406
HCO3 22.6
pCO2 36.0
Lytes also low on iSTAT
urea 3.57 (normal)
gluc was 1.925 (N= 4.11-7.95 mmol/L)
BE -2
Labwork shows normal pH with normal HCO3 and pCO2. All lytes below normal.
Lymphopenia
Ca++ slt low
USG 1.016
Repeated iSTAT 4.5 hours after admit; showed normal Na+ and Cl- with K+ just slightly below normal. Glucose normal. pH still normal.
**Has been producing lg amounts urine since admitted (~1750 mls in 5.5 hours = 10 ml/kg/hr 5-10x normal rate) - we have a urinary catheter in.
Continues to start to vocalize when not sedated on CRI meds - less vocal but whining and restless, stumbling - he is possibly less painful now (if he even was painful) but hard to assess due to altered consciousness (and I have never seen him pre-sedation/analgesia)
ASSESSMENT
Acuteness of onset suggest toxin - not many things cause hypoglycemia. Aside from medical issues such as insulinoma and severe hepatic disease (for both of which there is no history suggestive of these, no liver abn on labwork so far) - hypoglycemia not commonly seen with trauma, nor allergic reactions. Xylitol could cause hypoglycemia, diabetic meds (ie: oral anti-hyperglycemics) could cause. Not really anything else. No history of any of these but was off leash.
Allergic reaction could be a coincidental issue?
RHL lameness could be a secondary injury if Leo stumbled and hurt himself once he started being weak?
I'm not sure what is causing the polyuria. He may have received a large amount of fluids at the referring clinic but he was not there that long.
He is being maintained on a CRI of dexdomitor which is keeping him sleeping. Without it he is vocalizing and stumbling all over, agitated. Because he seemed painful at referring clinic and on palpation of RHL we have him on a fentanyl CRI as well. We are slowly tapering both down. When we tapered the DDM CRI too fast he woke up, initially was quiet and alert in sternal but then started to vocalize and stumble and fall around, wouldn't settle. We are planning on doing the orthogonal views of the thorax and the abdomen (VD views).
Does anyone have any brilliant ideas to pull all these things together, any suggestions for further workup or treatment?
☼ | Sounds plausible, any lumbar pain? | Any weight loss? |
Hello,
I have a puzzling case that I haven't been able to put all the various pieces together yet. I was hoping to tap into the collective brilliance of VIN.
We were presented with an acutely ill 3 year old pitbull. He was initially seen at a local clinic and then sent down to our emergency hospital, seen by a colleague and then transferred to me about 1 hour later for overnight care. The dog was initially ambulatory but came into our clinic non-ambulatory and I first saw him only after he had been given analgesia and sedation so I have never seen him un-sedated. I've written a summary of the information from the referring vet and what we've seen so far.
Leo seemed fine earlier today. He was with owner and very active, playing at local lake - not seen to have got into anything but was off leash and out of sight in bushes several times
Started to act odd, weak, looked gray, piloerection noted at some point along back.
Brought to local clinic and looked shocky, hypothermic (34.7oC, normal is 38.0-39oC) treated with IVF, seemed hunched and seemed unable to use RHL.
Frayed bloody nail on 5th digit RHL
Given analgesia (butorphanol)
Lateral rads taken at referring clinic showed aerophagia, poss FB in stomach (could be piece of rubber toy he was chewing last week). Some patchy mottling of mid to caudal lung fields (still need orthogonal views to assess further)
Came in to our clinic non-ambulatory, still hypothermic but improving,
Less shocky after IVF support, vitals improved, pink MM, temp normalized, HR and BP OK to increased
Started to vocalize and seem mentally altered
HR 120, BP 150
Hypoglycemic (1.9 mmol/L, normal is 4.11-7.95)
Given dextrose IV, K+ added to IVF, butorphanol repeated
Continued to vocalize loudly and be agitated, given alfaxolone IV which worked but didn't last long.
Seemed painful with palpation of RHL even while sedate.
Some dermatitis over legs and ventral body - these areas seemed to get more hyperemic between 18:30 and 19:30 (90 minutes of presentation to our clinic). According to owners he is prone to this, very reactive to many things, usually responds to anti-histamine and a steroid cream.
Bull's eye lesion found near right axilla (owner saw Leo yelp yesterday and has noticed wasps and thinks he might have been stung) - prone to allergic skin reactions, hives, rash.
LABWORK
CBC
WBC 11,300 ; lymphopenia (560)
Manual Hct 51%
PP 5.4
CHEM
Ca++ slt decr 1.92 (N=1.98-3.00 mmol/L)
Liver and renal values normal
TP low normal @ 52
Na+ decr @ 127 (N=144-160 mmol/L)
K+ decr @ 3.0 (N=3.5-5.8 mmol/L)
Cl low @ 99 (N= 109-122)
UA
USG 1.016 (sample collected in our hospital after he received IVF at referring clinic)
pH 8.0
sediment benign
no glucose or protein in urine
iSTAT
pH 7.406
HCO3 22.6
pCO2 36.0
Lytes also low on iSTAT
urea 3.57 (normal)
gluc was 1.925 (N= 4.11-7.95 mmol/L)
BE -2
Labwork shows normal pH with normal HCO3 and pCO2. All lytes below normal.
Lymphopenia
Ca++ slt low
USG 1.016
Repeated iSTAT 4.5 hours after admit; showed normal Na+ and Cl- with K+ just slightly below normal. Glucose normal. pH still normal.
**Has been producing lg amounts urine since admitted (~1750 mls in 5.5 hours = 10 ml/kg/hr 5-10x normal rate) - we have a urinary catheter in.
Continues to start to vocalize when not sedated on CRI meds - less vocal but whining and restless, stumbling - he is possibly less painful now (if he even was painful) but hard to assess due to altered consciousness (and I have never seen him pre-sedation/analgesia)
ASSESSMENT
Acuteness of onset suggest toxin - not many things cause hypoglycemia. Aside from medical issues such as insulinoma and severe hepatic disease (for both of which there is no history suggestive of these, no liver abn on labwork so far) - hypoglycemia not commonly seen with trauma, nor allergic reactions. Xylitol could cause hypoglycemia, diabetic meds (ie: oral anti-hyperglycemics) could cause. Not really anything else. No history of any of these but was off leash.
Allergic reaction could be a coincidental issue?
RHL lameness could be a secondary injury if Leo stumbled and hurt himself once he started being weak?
I'm not sure what is causing the polyuria. He may have received a large amount of fluids at the referring clinic but he was not there that long.
He is being maintained on a CRI of dexdomitor which is keeping him sleeping. Without it he is vocalizing and stumbling all over, agitated. Because he seemed painful at referring clinic and on palpation of RHL we have him on a fentanyl CRI as well. We are slowly tapering both down. When we tapered the DDM CRI too fast he woke up, initially was quiet and alert in sternal but then started to vocalize and stumble and fall around, wouldn't settle. We are planning on doing the orthogonal views of the thorax and the abdomen (VD views).
Does anyone have any brilliant ideas to pull all these things together, any suggestions for further workup or treatment?
☼ | Spinal reflexes? | Trial of anti-seizure meds? |
Hello,
I have a puzzling case that I haven't been able to put all the various pieces together yet. I was hoping to tap into the collective brilliance of VIN.
We were presented with an acutely ill 3 year old pitbull. He was initially seen at a local clinic and then sent down to our emergency hospital, seen by a colleague and then transferred to me about 1 hour later for overnight care. The dog was initially ambulatory but came into our clinic non-ambulatory and I first saw him only after he had been given analgesia and sedation so I have never seen him un-sedated. I've written a summary of the information from the referring vet and what we've seen so far.
Leo seemed fine earlier today. He was with owner and very active, playing at local lake - not seen to have got into anything but was off leash and out of sight in bushes several times
Started to act odd, weak, looked gray, piloerection noted at some point along back.
Brought to local clinic and looked shocky, hypothermic (34.7oC, normal is 38.0-39oC) treated with IVF, seemed hunched and seemed unable to use RHL.
Frayed bloody nail on 5th digit RHL
Given analgesia (butorphanol)
Lateral rads taken at referring clinic showed aerophagia, poss FB in stomach (could be piece of rubber toy he was chewing last week). Some patchy mottling of mid to caudal lung fields (still need orthogonal views to assess further)
Came in to our clinic non-ambulatory, still hypothermic but improving,
Less shocky after IVF support, vitals improved, pink MM, temp normalized, HR and BP OK to increased
Started to vocalize and seem mentally altered
HR 120, BP 150
Hypoglycemic (1.9 mmol/L, normal is 4.11-7.95)
Given dextrose IV, K+ added to IVF, butorphanol repeated
Continued to vocalize loudly and be agitated, given alfaxolone IV which worked but didn't last long.
Seemed painful with palpation of RHL even while sedate.
Some dermatitis over legs and ventral body - these areas seemed to get more hyperemic between 18:30 and 19:30 (90 minutes of presentation to our clinic). According to owners he is prone to this, very reactive to many things, usually responds to anti-histamine and a steroid cream.
Bull's eye lesion found near right axilla (owner saw Leo yelp yesterday and has noticed wasps and thinks he might have been stung) - prone to allergic skin reactions, hives, rash.
LABWORK
CBC
WBC 11,300 ; lymphopenia (560)
Manual Hct 51%
PP 5.4
CHEM
Ca++ slt decr 1.92 (N=1.98-3.00 mmol/L)
Liver and renal values normal
TP low normal @ 52
Na+ decr @ 127 (N=144-160 mmol/L)
K+ decr @ 3.0 (N=3.5-5.8 mmol/L)
Cl low @ 99 (N= 109-122)
UA
USG 1.016 (sample collected in our hospital after he received IVF at referring clinic)
pH 8.0
sediment benign
no glucose or protein in urine
iSTAT
pH 7.406
HCO3 22.6
pCO2 36.0
Lytes also low on iSTAT
urea 3.57 (normal)
gluc was 1.925 (N= 4.11-7.95 mmol/L)
BE -2
Labwork shows normal pH with normal HCO3 and pCO2. All lytes below normal.
Lymphopenia
Ca++ slt low
USG 1.016
Repeated iSTAT 4.5 hours after admit; showed normal Na+ and Cl- with K+ just slightly below normal. Glucose normal. pH still normal.
**Has been producing lg amounts urine since admitted (~1750 mls in 5.5 hours = 10 ml/kg/hr 5-10x normal rate) - we have a urinary catheter in.
Continues to start to vocalize when not sedated on CRI meds - less vocal but whining and restless, stumbling - he is possibly less painful now (if he even was painful) but hard to assess due to altered consciousness (and I have never seen him pre-sedation/analgesia)
ASSESSMENT
Acuteness of onset suggest toxin - not many things cause hypoglycemia. Aside from medical issues such as insulinoma and severe hepatic disease (for both of which there is no history suggestive of these, no liver abn on labwork so far) - hypoglycemia not commonly seen with trauma, nor allergic reactions. Xylitol could cause hypoglycemia, diabetic meds (ie: oral anti-hyperglycemics) could cause. Not really anything else. No history of any of these but was off leash.
Allergic reaction could be a coincidental issue?
RHL lameness could be a secondary injury if Leo stumbled and hurt himself once he started being weak?
I'm not sure what is causing the polyuria. He may have received a large amount of fluids at the referring clinic but he was not there that long.
He is being maintained on a CRI of dexdomitor which is keeping him sleeping. Without it he is vocalizing and stumbling all over, agitated. Because he seemed painful at referring clinic and on palpation of RHL we have him on a fentanyl CRI as well. We are slowly tapering both down. When we tapered the DDM CRI too fast he woke up, initially was quiet and alert in sternal but then started to vocalize and stumble and fall around, wouldn't settle. We are planning on doing the orthogonal views of the thorax and the abdomen (VD views).
Does anyone have any brilliant ideas to pull all these things together, any suggestions for further workup or treatment?
☼ | Able to assess postural reactions?cp? | Has the dose been increased? |
Hello,
I have a puzzling case that I haven't been able to put all the various pieces together yet. I was hoping to tap into the collective brilliance of VIN.
We were presented with an acutely ill 3 year old pitbull. He was initially seen at a local clinic and then sent down to our emergency hospital, seen by a colleague and then transferred to me about 1 hour later for overnight care. The dog was initially ambulatory but came into our clinic non-ambulatory and I first saw him only after he had been given analgesia and sedation so I have never seen him un-sedated. I've written a summary of the information from the referring vet and what we've seen so far.
Leo seemed fine earlier today. He was with owner and very active, playing at local lake - not seen to have got into anything but was off leash and out of sight in bushes several times
Started to act odd, weak, looked gray, piloerection noted at some point along back.
Brought to local clinic and looked shocky, hypothermic (34.7oC, normal is 38.0-39oC) treated with IVF, seemed hunched and seemed unable to use RHL.
Frayed bloody nail on 5th digit RHL
Given analgesia (butorphanol)
Lateral rads taken at referring clinic showed aerophagia, poss FB in stomach (could be piece of rubber toy he was chewing last week). Some patchy mottling of mid to caudal lung fields (still need orthogonal views to assess further)
Came in to our clinic non-ambulatory, still hypothermic but improving,
Less shocky after IVF support, vitals improved, pink MM, temp normalized, HR and BP OK to increased
Started to vocalize and seem mentally altered
HR 120, BP 150
Hypoglycemic (1.9 mmol/L, normal is 4.11-7.95)
Given dextrose IV, K+ added to IVF, butorphanol repeated
Continued to vocalize loudly and be agitated, given alfaxolone IV which worked but didn't last long.
Seemed painful with palpation of RHL even while sedate.
Some dermatitis over legs and ventral body - these areas seemed to get more hyperemic between 18:30 and 19:30 (90 minutes of presentation to our clinic). According to owners he is prone to this, very reactive to many things, usually responds to anti-histamine and a steroid cream.
Bull's eye lesion found near right axilla (owner saw Leo yelp yesterday and has noticed wasps and thinks he might have been stung) - prone to allergic skin reactions, hives, rash.
LABWORK
CBC
WBC 11,300 ; lymphopenia (560)
Manual Hct 51%
PP 5.4
CHEM
Ca++ slt decr 1.92 (N=1.98-3.00 mmol/L)
Liver and renal values normal
TP low normal @ 52
Na+ decr @ 127 (N=144-160 mmol/L)
K+ decr @ 3.0 (N=3.5-5.8 mmol/L)
Cl low @ 99 (N= 109-122)
UA
USG 1.016 (sample collected in our hospital after he received IVF at referring clinic)
pH 8.0
sediment benign
no glucose or protein in urine
iSTAT
pH 7.406
HCO3 22.6
pCO2 36.0
Lytes also low on iSTAT
urea 3.57 (normal)
gluc was 1.925 (N= 4.11-7.95 mmol/L)
BE -2
Labwork shows normal pH with normal HCO3 and pCO2. All lytes below normal.
Lymphopenia
Ca++ slt low
USG 1.016
Repeated iSTAT 4.5 hours after admit; showed normal Na+ and Cl- with K+ just slightly below normal. Glucose normal. pH still normal.
**Has been producing lg amounts urine since admitted (~1750 mls in 5.5 hours = 10 ml/kg/hr 5-10x normal rate) - we have a urinary catheter in.
Continues to start to vocalize when not sedated on CRI meds - less vocal but whining and restless, stumbling - he is possibly less painful now (if he even was painful) but hard to assess due to altered consciousness (and I have never seen him pre-sedation/analgesia)
ASSESSMENT
Acuteness of onset suggest toxin - not many things cause hypoglycemia. Aside from medical issues such as insulinoma and severe hepatic disease (for both of which there is no history suggestive of these, no liver abn on labwork so far) - hypoglycemia not commonly seen with trauma, nor allergic reactions. Xylitol could cause hypoglycemia, diabetic meds (ie: oral anti-hyperglycemics) could cause. Not really anything else. No history of any of these but was off leash.
Allergic reaction could be a coincidental issue?
RHL lameness could be a secondary injury if Leo stumbled and hurt himself once he started being weak?
I'm not sure what is causing the polyuria. He may have received a large amount of fluids at the referring clinic but he was not there that long.
He is being maintained on a CRI of dexdomitor which is keeping him sleeping. Without it he is vocalizing and stumbling all over, agitated. Because he seemed painful at referring clinic and on palpation of RHL we have him on a fentanyl CRI as well. We are slowly tapering both down. When we tapered the DDM CRI too fast he woke up, initially was quiet and alert in sternal but then started to vocalize and stumble and fall around, wouldn't settle. We are planning on doing the orthogonal views of the thorax and the abdomen (VD views).
Does anyone have any brilliant ideas to pull all these things together, any suggestions for further workup or treatment?
☼ | Cutaneous trunci response? | It sounds like her weight is stable on the 2 cups bid of w/d? |
Hello,
I have a puzzling case that I haven't been able to put all the various pieces together yet. I was hoping to tap into the collective brilliance of VIN.
We were presented with an acutely ill 3 year old pitbull. He was initially seen at a local clinic and then sent down to our emergency hospital, seen by a colleague and then transferred to me about 1 hour later for overnight care. The dog was initially ambulatory but came into our clinic non-ambulatory and I first saw him only after he had been given analgesia and sedation so I have never seen him un-sedated. I've written a summary of the information from the referring vet and what we've seen so far.
Leo seemed fine earlier today. He was with owner and very active, playing at local lake - not seen to have got into anything but was off leash and out of sight in bushes several times
Started to act odd, weak, looked gray, piloerection noted at some point along back.
Brought to local clinic and looked shocky, hypothermic (34.7oC, normal is 38.0-39oC) treated with IVF, seemed hunched and seemed unable to use RHL.
Frayed bloody nail on 5th digit RHL
Given analgesia (butorphanol)
Lateral rads taken at referring clinic showed aerophagia, poss FB in stomach (could be piece of rubber toy he was chewing last week). Some patchy mottling of mid to caudal lung fields (still need orthogonal views to assess further)
Came in to our clinic non-ambulatory, still hypothermic but improving,
Less shocky after IVF support, vitals improved, pink MM, temp normalized, HR and BP OK to increased
Started to vocalize and seem mentally altered
HR 120, BP 150
Hypoglycemic (1.9 mmol/L, normal is 4.11-7.95)
Given dextrose IV, K+ added to IVF, butorphanol repeated
Continued to vocalize loudly and be agitated, given alfaxolone IV which worked but didn't last long.
Seemed painful with palpation of RHL even while sedate.
Some dermatitis over legs and ventral body - these areas seemed to get more hyperemic between 18:30 and 19:30 (90 minutes of presentation to our clinic). According to owners he is prone to this, very reactive to many things, usually responds to anti-histamine and a steroid cream.
Bull's eye lesion found near right axilla (owner saw Leo yelp yesterday and has noticed wasps and thinks he might have been stung) - prone to allergic skin reactions, hives, rash.
LABWORK
CBC
WBC 11,300 ; lymphopenia (560)
Manual Hct 51%
PP 5.4
CHEM
Ca++ slt decr 1.92 (N=1.98-3.00 mmol/L)
Liver and renal values normal
TP low normal @ 52
Na+ decr @ 127 (N=144-160 mmol/L)
K+ decr @ 3.0 (N=3.5-5.8 mmol/L)
Cl low @ 99 (N= 109-122)
UA
USG 1.016 (sample collected in our hospital after he received IVF at referring clinic)
pH 8.0
sediment benign
no glucose or protein in urine
iSTAT
pH 7.406
HCO3 22.6
pCO2 36.0
Lytes also low on iSTAT
urea 3.57 (normal)
gluc was 1.925 (N= 4.11-7.95 mmol/L)
BE -2
Labwork shows normal pH with normal HCO3 and pCO2. All lytes below normal.
Lymphopenia
Ca++ slt low
USG 1.016
Repeated iSTAT 4.5 hours after admit; showed normal Na+ and Cl- with K+ just slightly below normal. Glucose normal. pH still normal.
**Has been producing lg amounts urine since admitted (~1750 mls in 5.5 hours = 10 ml/kg/hr 5-10x normal rate) - we have a urinary catheter in.
Continues to start to vocalize when not sedated on CRI meds - less vocal but whining and restless, stumbling - he is possibly less painful now (if he even was painful) but hard to assess due to altered consciousness (and I have never seen him pre-sedation/analgesia)
ASSESSMENT
Acuteness of onset suggest toxin - not many things cause hypoglycemia. Aside from medical issues such as insulinoma and severe hepatic disease (for both of which there is no history suggestive of these, no liver abn on labwork so far) - hypoglycemia not commonly seen with trauma, nor allergic reactions. Xylitol could cause hypoglycemia, diabetic meds (ie: oral anti-hyperglycemics) could cause. Not really anything else. No history of any of these but was off leash.
Allergic reaction could be a coincidental issue?
RHL lameness could be a secondary injury if Leo stumbled and hurt himself once he started being weak?
I'm not sure what is causing the polyuria. He may have received a large amount of fluids at the referring clinic but he was not there that long.
He is being maintained on a CRI of dexdomitor which is keeping him sleeping. Without it he is vocalizing and stumbling all over, agitated. Because he seemed painful at referring clinic and on palpation of RHL we have him on a fentanyl CRI as well. We are slowly tapering both down. When we tapered the DDM CRI too fast he woke up, initially was quiet and alert in sternal but then started to vocalize and stumble and fall around, wouldn't settle. We are planning on doing the orthogonal views of the thorax and the abdomen (VD views).
Does anyone have any brilliant ideas to pull all these things together, any suggestions for further workup or treatment?
☼ | Femoral pulses? | Has the dog been on this 120mg bid dose for quite some time? |
Hello,
I have a puzzling case that I haven't been able to put all the various pieces together yet. I was hoping to tap into the collective brilliance of VIN.
We were presented with an acutely ill 3 year old pitbull. He was initially seen at a local clinic and then sent down to our emergency hospital, seen by a colleague and then transferred to me about 1 hour later for overnight care. The dog was initially ambulatory but came into our clinic non-ambulatory and I first saw him only after he had been given analgesia and sedation so I have never seen him un-sedated. I've written a summary of the information from the referring vet and what we've seen so far.
Leo seemed fine earlier today. He was with owner and very active, playing at local lake - not seen to have got into anything but was off leash and out of sight in bushes several times
Started to act odd, weak, looked gray, piloerection noted at some point along back.
Brought to local clinic and looked shocky, hypothermic (34.7oC, normal is 38.0-39oC) treated with IVF, seemed hunched and seemed unable to use RHL.
Frayed bloody nail on 5th digit RHL
Given analgesia (butorphanol)
Lateral rads taken at referring clinic showed aerophagia, poss FB in stomach (could be piece of rubber toy he was chewing last week). Some patchy mottling of mid to caudal lung fields (still need orthogonal views to assess further)
Came in to our clinic non-ambulatory, still hypothermic but improving,
Less shocky after IVF support, vitals improved, pink MM, temp normalized, HR and BP OK to increased
Started to vocalize and seem mentally altered
HR 120, BP 150
Hypoglycemic (1.9 mmol/L, normal is 4.11-7.95)
Given dextrose IV, K+ added to IVF, butorphanol repeated
Continued to vocalize loudly and be agitated, given alfaxolone IV which worked but didn't last long.
Seemed painful with palpation of RHL even while sedate.
Some dermatitis over legs and ventral body - these areas seemed to get more hyperemic between 18:30 and 19:30 (90 minutes of presentation to our clinic). According to owners he is prone to this, very reactive to many things, usually responds to anti-histamine and a steroid cream.
Bull's eye lesion found near right axilla (owner saw Leo yelp yesterday and has noticed wasps and thinks he might have been stung) - prone to allergic skin reactions, hives, rash.
LABWORK
CBC
WBC 11,300 ; lymphopenia (560)
Manual Hct 51%
PP 5.4
CHEM
Ca++ slt decr 1.92 (N=1.98-3.00 mmol/L)
Liver and renal values normal
TP low normal @ 52
Na+ decr @ 127 (N=144-160 mmol/L)
K+ decr @ 3.0 (N=3.5-5.8 mmol/L)
Cl low @ 99 (N= 109-122)
UA
USG 1.016 (sample collected in our hospital after he received IVF at referring clinic)
pH 8.0
sediment benign
no glucose or protein in urine
iSTAT
pH 7.406
HCO3 22.6
pCO2 36.0
Lytes also low on iSTAT
urea 3.57 (normal)
gluc was 1.925 (N= 4.11-7.95 mmol/L)
BE -2
Labwork shows normal pH with normal HCO3 and pCO2. All lytes below normal.
Lymphopenia
Ca++ slt low
USG 1.016
Repeated iSTAT 4.5 hours after admit; showed normal Na+ and Cl- with K+ just slightly below normal. Glucose normal. pH still normal.
**Has been producing lg amounts urine since admitted (~1750 mls in 5.5 hours = 10 ml/kg/hr 5-10x normal rate) - we have a urinary catheter in.
Continues to start to vocalize when not sedated on CRI meds - less vocal but whining and restless, stumbling - he is possibly less painful now (if he even was painful) but hard to assess due to altered consciousness (and I have never seen him pre-sedation/analgesia)
ASSESSMENT
Acuteness of onset suggest toxin - not many things cause hypoglycemia. Aside from medical issues such as insulinoma and severe hepatic disease (for both of which there is no history suggestive of these, no liver abn on labwork so far) - hypoglycemia not commonly seen with trauma, nor allergic reactions. Xylitol could cause hypoglycemia, diabetic meds (ie: oral anti-hyperglycemics) could cause. Not really anything else. No history of any of these but was off leash.
Allergic reaction could be a coincidental issue?
RHL lameness could be a secondary injury if Leo stumbled and hurt himself once he started being weak?
I'm not sure what is causing the polyuria. He may have received a large amount of fluids at the referring clinic but he was not there that long.
He is being maintained on a CRI of dexdomitor which is keeping him sleeping. Without it he is vocalizing and stumbling all over, agitated. Because he seemed painful at referring clinic and on palpation of RHL we have him on a fentanyl CRI as well. We are slowly tapering both down. When we tapered the DDM CRI too fast he woke up, initially was quiet and alert in sternal but then started to vocalize and stumble and fall around, wouldn't settle. We are planning on doing the orthogonal views of the thorax and the abdomen (VD views).
Does anyone have any brilliant ideas to pull all these things together, any suggestions for further workup or treatment?
☼ | Extremity temperature? | What site does this owner use? |
Hello,
I have a puzzling case that I haven't been able to put all the various pieces together yet. I was hoping to tap into the collective brilliance of VIN.
We were presented with an acutely ill 3 year old pitbull. He was initially seen at a local clinic and then sent down to our emergency hospital, seen by a colleague and then transferred to me about 1 hour later for overnight care. The dog was initially ambulatory but came into our clinic non-ambulatory and I first saw him only after he had been given analgesia and sedation so I have never seen him un-sedated. I've written a summary of the information from the referring vet and what we've seen so far.
Leo seemed fine earlier today. He was with owner and very active, playing at local lake - not seen to have got into anything but was off leash and out of sight in bushes several times
Started to act odd, weak, looked gray, piloerection noted at some point along back.
Brought to local clinic and looked shocky, hypothermic (34.7oC, normal is 38.0-39oC) treated with IVF, seemed hunched and seemed unable to use RHL.
Frayed bloody nail on 5th digit RHL
Given analgesia (butorphanol)
Lateral rads taken at referring clinic showed aerophagia, poss FB in stomach (could be piece of rubber toy he was chewing last week). Some patchy mottling of mid to caudal lung fields (still need orthogonal views to assess further)
Came in to our clinic non-ambulatory, still hypothermic but improving,
Less shocky after IVF support, vitals improved, pink MM, temp normalized, HR and BP OK to increased
Started to vocalize and seem mentally altered
HR 120, BP 150
Hypoglycemic (1.9 mmol/L, normal is 4.11-7.95)
Given dextrose IV, K+ added to IVF, butorphanol repeated
Continued to vocalize loudly and be agitated, given alfaxolone IV which worked but didn't last long.
Seemed painful with palpation of RHL even while sedate.
Some dermatitis over legs and ventral body - these areas seemed to get more hyperemic between 18:30 and 19:30 (90 minutes of presentation to our clinic). According to owners he is prone to this, very reactive to many things, usually responds to anti-histamine and a steroid cream.
Bull's eye lesion found near right axilla (owner saw Leo yelp yesterday and has noticed wasps and thinks he might have been stung) - prone to allergic skin reactions, hives, rash.
LABWORK
CBC
WBC 11,300 ; lymphopenia (560)
Manual Hct 51%
PP 5.4
CHEM
Ca++ slt decr 1.92 (N=1.98-3.00 mmol/L)
Liver and renal values normal
TP low normal @ 52
Na+ decr @ 127 (N=144-160 mmol/L)
K+ decr @ 3.0 (N=3.5-5.8 mmol/L)
Cl low @ 99 (N= 109-122)
UA
USG 1.016 (sample collected in our hospital after he received IVF at referring clinic)
pH 8.0
sediment benign
no glucose or protein in urine
iSTAT
pH 7.406
HCO3 22.6
pCO2 36.0
Lytes also low on iSTAT
urea 3.57 (normal)
gluc was 1.925 (N= 4.11-7.95 mmol/L)
BE -2
Labwork shows normal pH with normal HCO3 and pCO2. All lytes below normal.
Lymphopenia
Ca++ slt low
USG 1.016
Repeated iSTAT 4.5 hours after admit; showed normal Na+ and Cl- with K+ just slightly below normal. Glucose normal. pH still normal.
**Has been producing lg amounts urine since admitted (~1750 mls in 5.5 hours = 10 ml/kg/hr 5-10x normal rate) - we have a urinary catheter in.
Continues to start to vocalize when not sedated on CRI meds - less vocal but whining and restless, stumbling - he is possibly less painful now (if he even was painful) but hard to assess due to altered consciousness (and I have never seen him pre-sedation/analgesia)
ASSESSMENT
Acuteness of onset suggest toxin - not many things cause hypoglycemia. Aside from medical issues such as insulinoma and severe hepatic disease (for both of which there is no history suggestive of these, no liver abn on labwork so far) - hypoglycemia not commonly seen with trauma, nor allergic reactions. Xylitol could cause hypoglycemia, diabetic meds (ie: oral anti-hyperglycemics) could cause. Not really anything else. No history of any of these but was off leash.
Allergic reaction could be a coincidental issue?
RHL lameness could be a secondary injury if Leo stumbled and hurt himself once he started being weak?
I'm not sure what is causing the polyuria. He may have received a large amount of fluids at the referring clinic but he was not there that long.
He is being maintained on a CRI of dexdomitor which is keeping him sleeping. Without it he is vocalizing and stumbling all over, agitated. Because he seemed painful at referring clinic and on palpation of RHL we have him on a fentanyl CRI as well. We are slowly tapering both down. When we tapered the DDM CRI too fast he woke up, initially was quiet and alert in sternal but then started to vocalize and stumble and fall around, wouldn't settle. We are planning on doing the orthogonal views of the thorax and the abdomen (VD views).
Does anyone have any brilliant ideas to pull all these things together, any suggestions for further workup or treatment?
☼ | Did you ascultate a murmur? | What brand of glucometer is the owner getting? |
Hello,
I have a puzzling case that I haven't been able to put all the various pieces together yet. I was hoping to tap into the collective brilliance of VIN.
We were presented with an acutely ill 3 year old pitbull. He was initially seen at a local clinic and then sent down to our emergency hospital, seen by a colleague and then transferred to me about 1 hour later for overnight care. The dog was initially ambulatory but came into our clinic non-ambulatory and I first saw him only after he had been given analgesia and sedation so I have never seen him un-sedated. I've written a summary of the information from the referring vet and what we've seen so far.
Leo seemed fine earlier today. He was with owner and very active, playing at local lake - not seen to have got into anything but was off leash and out of sight in bushes several times
Started to act odd, weak, looked gray, piloerection noted at some point along back.
Brought to local clinic and looked shocky, hypothermic (34.7oC, normal is 38.0-39oC) treated with IVF, seemed hunched and seemed unable to use RHL.
Frayed bloody nail on 5th digit RHL
Given analgesia (butorphanol)
Lateral rads taken at referring clinic showed aerophagia, poss FB in stomach (could be piece of rubber toy he was chewing last week). Some patchy mottling of mid to caudal lung fields (still need orthogonal views to assess further)
Came in to our clinic non-ambulatory, still hypothermic but improving,
Less shocky after IVF support, vitals improved, pink MM, temp normalized, HR and BP OK to increased
Started to vocalize and seem mentally altered
HR 120, BP 150
Hypoglycemic (1.9 mmol/L, normal is 4.11-7.95)
Given dextrose IV, K+ added to IVF, butorphanol repeated
Continued to vocalize loudly and be agitated, given alfaxolone IV which worked but didn't last long.
Seemed painful with palpation of RHL even while sedate.
Some dermatitis over legs and ventral body - these areas seemed to get more hyperemic between 18:30 and 19:30 (90 minutes of presentation to our clinic). According to owners he is prone to this, very reactive to many things, usually responds to anti-histamine and a steroid cream.
Bull's eye lesion found near right axilla (owner saw Leo yelp yesterday and has noticed wasps and thinks he might have been stung) - prone to allergic skin reactions, hives, rash.
LABWORK
CBC
WBC 11,300 ; lymphopenia (560)
Manual Hct 51%
PP 5.4
CHEM
Ca++ slt decr 1.92 (N=1.98-3.00 mmol/L)
Liver and renal values normal
TP low normal @ 52
Na+ decr @ 127 (N=144-160 mmol/L)
K+ decr @ 3.0 (N=3.5-5.8 mmol/L)
Cl low @ 99 (N= 109-122)
UA
USG 1.016 (sample collected in our hospital after he received IVF at referring clinic)
pH 8.0
sediment benign
no glucose or protein in urine
iSTAT
pH 7.406
HCO3 22.6
pCO2 36.0
Lytes also low on iSTAT
urea 3.57 (normal)
gluc was 1.925 (N= 4.11-7.95 mmol/L)
BE -2
Labwork shows normal pH with normal HCO3 and pCO2. All lytes below normal.
Lymphopenia
Ca++ slt low
USG 1.016
Repeated iSTAT 4.5 hours after admit; showed normal Na+ and Cl- with K+ just slightly below normal. Glucose normal. pH still normal.
**Has been producing lg amounts urine since admitted (~1750 mls in 5.5 hours = 10 ml/kg/hr 5-10x normal rate) - we have a urinary catheter in.
Continues to start to vocalize when not sedated on CRI meds - less vocal but whining and restless, stumbling - he is possibly less painful now (if he even was painful) but hard to assess due to altered consciousness (and I have never seen him pre-sedation/analgesia)
ASSESSMENT
Acuteness of onset suggest toxin - not many things cause hypoglycemia. Aside from medical issues such as insulinoma and severe hepatic disease (for both of which there is no history suggestive of these, no liver abn on labwork so far) - hypoglycemia not commonly seen with trauma, nor allergic reactions. Xylitol could cause hypoglycemia, diabetic meds (ie: oral anti-hyperglycemics) could cause. Not really anything else. No history of any of these but was off leash.
Allergic reaction could be a coincidental issue?
RHL lameness could be a secondary injury if Leo stumbled and hurt himself once he started being weak?
I'm not sure what is causing the polyuria. He may have received a large amount of fluids at the referring clinic but he was not there that long.
He is being maintained on a CRI of dexdomitor which is keeping him sleeping. Without it he is vocalizing and stumbling all over, agitated. Because he seemed painful at referring clinic and on palpation of RHL we have him on a fentanyl CRI as well. We are slowly tapering both down. When we tapered the DDM CRI too fast he woke up, initially was quiet and alert in sternal but then started to vocalize and stumble and fall around, wouldn't settle. We are planning on doing the orthogonal views of the thorax and the abdomen (VD views).
Does anyone have any brilliant ideas to pull all these things together, any suggestions for further workup or treatment?
☼ | Run an ecg strip? | Can you talk to them a bit more to see if they can give you more info as to whether this might be a seizure versus syncope? |
Hello,
I have a puzzling case that I haven't been able to put all the various pieces together yet. I was hoping to tap into the collective brilliance of VIN.
We were presented with an acutely ill 3 year old pitbull. He was initially seen at a local clinic and then sent down to our emergency hospital, seen by a colleague and then transferred to me about 1 hour later for overnight care. The dog was initially ambulatory but came into our clinic non-ambulatory and I first saw him only after he had been given analgesia and sedation so I have never seen him un-sedated. I've written a summary of the information from the referring vet and what we've seen so far.
Leo seemed fine earlier today. He was with owner and very active, playing at local lake - not seen to have got into anything but was off leash and out of sight in bushes several times
Started to act odd, weak, looked gray, piloerection noted at some point along back.
Brought to local clinic and looked shocky, hypothermic (34.7oC, normal is 38.0-39oC) treated with IVF, seemed hunched and seemed unable to use RHL.
Frayed bloody nail on 5th digit RHL
Given analgesia (butorphanol)
Lateral rads taken at referring clinic showed aerophagia, poss FB in stomach (could be piece of rubber toy he was chewing last week). Some patchy mottling of mid to caudal lung fields (still need orthogonal views to assess further)
Came in to our clinic non-ambulatory, still hypothermic but improving,
Less shocky after IVF support, vitals improved, pink MM, temp normalized, HR and BP OK to increased
Started to vocalize and seem mentally altered
HR 120, BP 150
Hypoglycemic (1.9 mmol/L, normal is 4.11-7.95)
Given dextrose IV, K+ added to IVF, butorphanol repeated
Continued to vocalize loudly and be agitated, given alfaxolone IV which worked but didn't last long.
Seemed painful with palpation of RHL even while sedate.
Some dermatitis over legs and ventral body - these areas seemed to get more hyperemic between 18:30 and 19:30 (90 minutes of presentation to our clinic). According to owners he is prone to this, very reactive to many things, usually responds to anti-histamine and a steroid cream.
Bull's eye lesion found near right axilla (owner saw Leo yelp yesterday and has noticed wasps and thinks he might have been stung) - prone to allergic skin reactions, hives, rash.
LABWORK
CBC
WBC 11,300 ; lymphopenia (560)
Manual Hct 51%
PP 5.4
CHEM
Ca++ slt decr 1.92 (N=1.98-3.00 mmol/L)
Liver and renal values normal
TP low normal @ 52
Na+ decr @ 127 (N=144-160 mmol/L)
K+ decr @ 3.0 (N=3.5-5.8 mmol/L)
Cl low @ 99 (N= 109-122)
UA
USG 1.016 (sample collected in our hospital after he received IVF at referring clinic)
pH 8.0
sediment benign
no glucose or protein in urine
iSTAT
pH 7.406
HCO3 22.6
pCO2 36.0
Lytes also low on iSTAT
urea 3.57 (normal)
gluc was 1.925 (N= 4.11-7.95 mmol/L)
BE -2
Labwork shows normal pH with normal HCO3 and pCO2. All lytes below normal.
Lymphopenia
Ca++ slt low
USG 1.016
Repeated iSTAT 4.5 hours after admit; showed normal Na+ and Cl- with K+ just slightly below normal. Glucose normal. pH still normal.
**Has been producing lg amounts urine since admitted (~1750 mls in 5.5 hours = 10 ml/kg/hr 5-10x normal rate) - we have a urinary catheter in.
Continues to start to vocalize when not sedated on CRI meds - less vocal but whining and restless, stumbling - he is possibly less painful now (if he even was painful) but hard to assess due to altered consciousness (and I have never seen him pre-sedation/analgesia)
ASSESSMENT
Acuteness of onset suggest toxin - not many things cause hypoglycemia. Aside from medical issues such as insulinoma and severe hepatic disease (for both of which there is no history suggestive of these, no liver abn on labwork so far) - hypoglycemia not commonly seen with trauma, nor allergic reactions. Xylitol could cause hypoglycemia, diabetic meds (ie: oral anti-hyperglycemics) could cause. Not really anything else. No history of any of these but was off leash.
Allergic reaction could be a coincidental issue?
RHL lameness could be a secondary injury if Leo stumbled and hurt himself once he started being weak?
I'm not sure what is causing the polyuria. He may have received a large amount of fluids at the referring clinic but he was not there that long.
He is being maintained on a CRI of dexdomitor which is keeping him sleeping. Without it he is vocalizing and stumbling all over, agitated. Because he seemed painful at referring clinic and on palpation of RHL we have him on a fentanyl CRI as well. We are slowly tapering both down. When we tapered the DDM CRI too fast he woke up, initially was quiet and alert in sternal but then started to vocalize and stumble and fall around, wouldn't settle. We are planning on doing the orthogonal views of the thorax and the abdomen (VD views).
Does anyone have any brilliant ideas to pull all these things together, any suggestions for further workup or treatment?
☼ | Did the heart look abnormal on the view you have? | Owners are feeding no treats and an amount of food for lean body weight divided and given twice a day along with the insulin? |
Hello,
I have a puzzling case that I haven't been able to put all the various pieces together yet. I was hoping to tap into the collective brilliance of VIN.
We were presented with an acutely ill 3 year old pitbull. He was initially seen at a local clinic and then sent down to our emergency hospital, seen by a colleague and then transferred to me about 1 hour later for overnight care. The dog was initially ambulatory but came into our clinic non-ambulatory and I first saw him only after he had been given analgesia and sedation so I have never seen him un-sedated. I've written a summary of the information from the referring vet and what we've seen so far.
Leo seemed fine earlier today. He was with owner and very active, playing at local lake - not seen to have got into anything but was off leash and out of sight in bushes several times
Started to act odd, weak, looked gray, piloerection noted at some point along back.
Brought to local clinic and looked shocky, hypothermic (34.7oC, normal is 38.0-39oC) treated with IVF, seemed hunched and seemed unable to use RHL.
Frayed bloody nail on 5th digit RHL
Given analgesia (butorphanol)
Lateral rads taken at referring clinic showed aerophagia, poss FB in stomach (could be piece of rubber toy he was chewing last week). Some patchy mottling of mid to caudal lung fields (still need orthogonal views to assess further)
Came in to our clinic non-ambulatory, still hypothermic but improving,
Less shocky after IVF support, vitals improved, pink MM, temp normalized, HR and BP OK to increased
Started to vocalize and seem mentally altered
HR 120, BP 150
Hypoglycemic (1.9 mmol/L, normal is 4.11-7.95)
Given dextrose IV, K+ added to IVF, butorphanol repeated
Continued to vocalize loudly and be agitated, given alfaxolone IV which worked but didn't last long.
Seemed painful with palpation of RHL even while sedate.
Some dermatitis over legs and ventral body - these areas seemed to get more hyperemic between 18:30 and 19:30 (90 minutes of presentation to our clinic). According to owners he is prone to this, very reactive to many things, usually responds to anti-histamine and a steroid cream.
Bull's eye lesion found near right axilla (owner saw Leo yelp yesterday and has noticed wasps and thinks he might have been stung) - prone to allergic skin reactions, hives, rash.
LABWORK
CBC
WBC 11,300 ; lymphopenia (560)
Manual Hct 51%
PP 5.4
CHEM
Ca++ slt decr 1.92 (N=1.98-3.00 mmol/L)
Liver and renal values normal
TP low normal @ 52
Na+ decr @ 127 (N=144-160 mmol/L)
K+ decr @ 3.0 (N=3.5-5.8 mmol/L)
Cl low @ 99 (N= 109-122)
UA
USG 1.016 (sample collected in our hospital after he received IVF at referring clinic)
pH 8.0
sediment benign
no glucose or protein in urine
iSTAT
pH 7.406
HCO3 22.6
pCO2 36.0
Lytes also low on iSTAT
urea 3.57 (normal)
gluc was 1.925 (N= 4.11-7.95 mmol/L)
BE -2
Labwork shows normal pH with normal HCO3 and pCO2. All lytes below normal.
Lymphopenia
Ca++ slt low
USG 1.016
Repeated iSTAT 4.5 hours after admit; showed normal Na+ and Cl- with K+ just slightly below normal. Glucose normal. pH still normal.
**Has been producing lg amounts urine since admitted (~1750 mls in 5.5 hours = 10 ml/kg/hr 5-10x normal rate) - we have a urinary catheter in.
Continues to start to vocalize when not sedated on CRI meds - less vocal but whining and restless, stumbling - he is possibly less painful now (if he even was painful) but hard to assess due to altered consciousness (and I have never seen him pre-sedation/analgesia)
ASSESSMENT
Acuteness of onset suggest toxin - not many things cause hypoglycemia. Aside from medical issues such as insulinoma and severe hepatic disease (for both of which there is no history suggestive of these, no liver abn on labwork so far) - hypoglycemia not commonly seen with trauma, nor allergic reactions. Xylitol could cause hypoglycemia, diabetic meds (ie: oral anti-hyperglycemics) could cause. Not really anything else. No history of any of these but was off leash.
Allergic reaction could be a coincidental issue?
RHL lameness could be a secondary injury if Leo stumbled and hurt himself once he started being weak?
I'm not sure what is causing the polyuria. He may have received a large amount of fluids at the referring clinic but he was not there that long.
He is being maintained on a CRI of dexdomitor which is keeping him sleeping. Without it he is vocalizing and stumbling all over, agitated. Because he seemed painful at referring clinic and on palpation of RHL we have him on a fentanyl CRI as well. We are slowly tapering both down. When we tapered the DDM CRI too fast he woke up, initially was quiet and alert in sternal but then started to vocalize and stumble and fall around, wouldn't settle. We are planning on doing the orthogonal views of the thorax and the abdomen (VD views).
Does anyone have any brilliant ideas to pull all these things together, any suggestions for further workup or treatment?
☼ | Is he having any respiratory issues or adventitial lung sounds? | Did you run the ldds at a commercial lab? |
Hello,
I have a puzzling case that I haven't been able to put all the various pieces together yet. I was hoping to tap into the collective brilliance of VIN.
We were presented with an acutely ill 3 year old pitbull. He was initially seen at a local clinic and then sent down to our emergency hospital, seen by a colleague and then transferred to me about 1 hour later for overnight care. The dog was initially ambulatory but came into our clinic non-ambulatory and I first saw him only after he had been given analgesia and sedation so I have never seen him un-sedated. I've written a summary of the information from the referring vet and what we've seen so far.
Leo seemed fine earlier today. He was with owner and very active, playing at local lake - not seen to have got into anything but was off leash and out of sight in bushes several times
Started to act odd, weak, looked gray, piloerection noted at some point along back.
Brought to local clinic and looked shocky, hypothermic (34.7oC, normal is 38.0-39oC) treated with IVF, seemed hunched and seemed unable to use RHL.
Frayed bloody nail on 5th digit RHL
Given analgesia (butorphanol)
Lateral rads taken at referring clinic showed aerophagia, poss FB in stomach (could be piece of rubber toy he was chewing last week). Some patchy mottling of mid to caudal lung fields (still need orthogonal views to assess further)
Came in to our clinic non-ambulatory, still hypothermic but improving,
Less shocky after IVF support, vitals improved, pink MM, temp normalized, HR and BP OK to increased
Started to vocalize and seem mentally altered
HR 120, BP 150
Hypoglycemic (1.9 mmol/L, normal is 4.11-7.95)
Given dextrose IV, K+ added to IVF, butorphanol repeated
Continued to vocalize loudly and be agitated, given alfaxolone IV which worked but didn't last long.
Seemed painful with palpation of RHL even while sedate.
Some dermatitis over legs and ventral body - these areas seemed to get more hyperemic between 18:30 and 19:30 (90 minutes of presentation to our clinic). According to owners he is prone to this, very reactive to many things, usually responds to anti-histamine and a steroid cream.
Bull's eye lesion found near right axilla (owner saw Leo yelp yesterday and has noticed wasps and thinks he might have been stung) - prone to allergic skin reactions, hives, rash.
LABWORK
CBC
WBC 11,300 ; lymphopenia (560)
Manual Hct 51%
PP 5.4
CHEM
Ca++ slt decr 1.92 (N=1.98-3.00 mmol/L)
Liver and renal values normal
TP low normal @ 52
Na+ decr @ 127 (N=144-160 mmol/L)
K+ decr @ 3.0 (N=3.5-5.8 mmol/L)
Cl low @ 99 (N= 109-122)
UA
USG 1.016 (sample collected in our hospital after he received IVF at referring clinic)
pH 8.0
sediment benign
no glucose or protein in urine
iSTAT
pH 7.406
HCO3 22.6
pCO2 36.0
Lytes also low on iSTAT
urea 3.57 (normal)
gluc was 1.925 (N= 4.11-7.95 mmol/L)
BE -2
Labwork shows normal pH with normal HCO3 and pCO2. All lytes below normal.
Lymphopenia
Ca++ slt low
USG 1.016
Repeated iSTAT 4.5 hours after admit; showed normal Na+ and Cl- with K+ just slightly below normal. Glucose normal. pH still normal.
**Has been producing lg amounts urine since admitted (~1750 mls in 5.5 hours = 10 ml/kg/hr 5-10x normal rate) - we have a urinary catheter in.
Continues to start to vocalize when not sedated on CRI meds - less vocal but whining and restless, stumbling - he is possibly less painful now (if he even was painful) but hard to assess due to altered consciousness (and I have never seen him pre-sedation/analgesia)
ASSESSMENT
Acuteness of onset suggest toxin - not many things cause hypoglycemia. Aside from medical issues such as insulinoma and severe hepatic disease (for both of which there is no history suggestive of these, no liver abn on labwork so far) - hypoglycemia not commonly seen with trauma, nor allergic reactions. Xylitol could cause hypoglycemia, diabetic meds (ie: oral anti-hyperglycemics) could cause. Not really anything else. No history of any of these but was off leash.
Allergic reaction could be a coincidental issue?
RHL lameness could be a secondary injury if Leo stumbled and hurt himself once he started being weak?
I'm not sure what is causing the polyuria. He may have received a large amount of fluids at the referring clinic but he was not there that long.
He is being maintained on a CRI of dexdomitor which is keeping him sleeping. Without it he is vocalizing and stumbling all over, agitated. Because he seemed painful at referring clinic and on palpation of RHL we have him on a fentanyl CRI as well. We are slowly tapering both down. When we tapered the DDM CRI too fast he woke up, initially was quiet and alert in sternal but then started to vocalize and stumble and fall around, wouldn't settle. We are planning on doing the orthogonal views of the thorax and the abdomen (VD views).
Does anyone have any brilliant ideas to pull all these things together, any suggestions for further workup or treatment?
☼ | 3-view chest rads would be optimal and if you can post them so we can take a look? | What exactly were the numbers for the ldds? |
Hello,
I have a puzzling case that I haven't been able to put all the various pieces together yet. I was hoping to tap into the collective brilliance of VIN.
We were presented with an acutely ill 3 year old pitbull. He was initially seen at a local clinic and then sent down to our emergency hospital, seen by a colleague and then transferred to me about 1 hour later for overnight care. The dog was initially ambulatory but came into our clinic non-ambulatory and I first saw him only after he had been given analgesia and sedation so I have never seen him un-sedated. I've written a summary of the information from the referring vet and what we've seen so far.
Leo seemed fine earlier today. He was with owner and very active, playing at local lake - not seen to have got into anything but was off leash and out of sight in bushes several times
Started to act odd, weak, looked gray, piloerection noted at some point along back.
Brought to local clinic and looked shocky, hypothermic (34.7oC, normal is 38.0-39oC) treated with IVF, seemed hunched and seemed unable to use RHL.
Frayed bloody nail on 5th digit RHL
Given analgesia (butorphanol)
Lateral rads taken at referring clinic showed aerophagia, poss FB in stomach (could be piece of rubber toy he was chewing last week). Some patchy mottling of mid to caudal lung fields (still need orthogonal views to assess further)
Came in to our clinic non-ambulatory, still hypothermic but improving,
Less shocky after IVF support, vitals improved, pink MM, temp normalized, HR and BP OK to increased
Started to vocalize and seem mentally altered
HR 120, BP 150
Hypoglycemic (1.9 mmol/L, normal is 4.11-7.95)
Given dextrose IV, K+ added to IVF, butorphanol repeated
Continued to vocalize loudly and be agitated, given alfaxolone IV which worked but didn't last long.
Seemed painful with palpation of RHL even while sedate.
Some dermatitis over legs and ventral body - these areas seemed to get more hyperemic between 18:30 and 19:30 (90 minutes of presentation to our clinic). According to owners he is prone to this, very reactive to many things, usually responds to anti-histamine and a steroid cream.
Bull's eye lesion found near right axilla (owner saw Leo yelp yesterday and has noticed wasps and thinks he might have been stung) - prone to allergic skin reactions, hives, rash.
LABWORK
CBC
WBC 11,300 ; lymphopenia (560)
Manual Hct 51%
PP 5.4
CHEM
Ca++ slt decr 1.92 (N=1.98-3.00 mmol/L)
Liver and renal values normal
TP low normal @ 52
Na+ decr @ 127 (N=144-160 mmol/L)
K+ decr @ 3.0 (N=3.5-5.8 mmol/L)
Cl low @ 99 (N= 109-122)
UA
USG 1.016 (sample collected in our hospital after he received IVF at referring clinic)
pH 8.0
sediment benign
no glucose or protein in urine
iSTAT
pH 7.406
HCO3 22.6
pCO2 36.0
Lytes also low on iSTAT
urea 3.57 (normal)
gluc was 1.925 (N= 4.11-7.95 mmol/L)
BE -2
Labwork shows normal pH with normal HCO3 and pCO2. All lytes below normal.
Lymphopenia
Ca++ slt low
USG 1.016
Repeated iSTAT 4.5 hours after admit; showed normal Na+ and Cl- with K+ just slightly below normal. Glucose normal. pH still normal.
**Has been producing lg amounts urine since admitted (~1750 mls in 5.5 hours = 10 ml/kg/hr 5-10x normal rate) - we have a urinary catheter in.
Continues to start to vocalize when not sedated on CRI meds - less vocal but whining and restless, stumbling - he is possibly less painful now (if he even was painful) but hard to assess due to altered consciousness (and I have never seen him pre-sedation/analgesia)
ASSESSMENT
Acuteness of onset suggest toxin - not many things cause hypoglycemia. Aside from medical issues such as insulinoma and severe hepatic disease (for both of which there is no history suggestive of these, no liver abn on labwork so far) - hypoglycemia not commonly seen with trauma, nor allergic reactions. Xylitol could cause hypoglycemia, diabetic meds (ie: oral anti-hyperglycemics) could cause. Not really anything else. No history of any of these but was off leash.
Allergic reaction could be a coincidental issue?
RHL lameness could be a secondary injury if Leo stumbled and hurt himself once he started being weak?
I'm not sure what is causing the polyuria. He may have received a large amount of fluids at the referring clinic but he was not there that long.
He is being maintained on a CRI of dexdomitor which is keeping him sleeping. Without it he is vocalizing and stumbling all over, agitated. Because he seemed painful at referring clinic and on palpation of RHL we have him on a fentanyl CRI as well. We are slowly tapering both down. When we tapered the DDM CRI too fast he woke up, initially was quiet and alert in sternal but then started to vocalize and stumble and fall around, wouldn't settle. We are planning on doing the orthogonal views of the thorax and the abdomen (VD views).
Does anyone have any brilliant ideas to pull all these things together, any suggestions for further workup or treatment?
☼ | Any evidence of a coagulopathy? | Any secondary bacterial infections to take care of? |
Hello,
I have a puzzling case that I haven't been able to put all the various pieces together yet. I was hoping to tap into the collective brilliance of VIN.
We were presented with an acutely ill 3 year old pitbull. He was initially seen at a local clinic and then sent down to our emergency hospital, seen by a colleague and then transferred to me about 1 hour later for overnight care. The dog was initially ambulatory but came into our clinic non-ambulatory and I first saw him only after he had been given analgesia and sedation so I have never seen him un-sedated. I've written a summary of the information from the referring vet and what we've seen so far.
Leo seemed fine earlier today. He was with owner and very active, playing at local lake - not seen to have got into anything but was off leash and out of sight in bushes several times
Started to act odd, weak, looked gray, piloerection noted at some point along back.
Brought to local clinic and looked shocky, hypothermic (34.7oC, normal is 38.0-39oC) treated with IVF, seemed hunched and seemed unable to use RHL.
Frayed bloody nail on 5th digit RHL
Given analgesia (butorphanol)
Lateral rads taken at referring clinic showed aerophagia, poss FB in stomach (could be piece of rubber toy he was chewing last week). Some patchy mottling of mid to caudal lung fields (still need orthogonal views to assess further)
Came in to our clinic non-ambulatory, still hypothermic but improving,
Less shocky after IVF support, vitals improved, pink MM, temp normalized, HR and BP OK to increased
Started to vocalize and seem mentally altered
HR 120, BP 150
Hypoglycemic (1.9 mmol/L, normal is 4.11-7.95)
Given dextrose IV, K+ added to IVF, butorphanol repeated
Continued to vocalize loudly and be agitated, given alfaxolone IV which worked but didn't last long.
Seemed painful with palpation of RHL even while sedate.
Some dermatitis over legs and ventral body - these areas seemed to get more hyperemic between 18:30 and 19:30 (90 minutes of presentation to our clinic). According to owners he is prone to this, very reactive to many things, usually responds to anti-histamine and a steroid cream.
Bull's eye lesion found near right axilla (owner saw Leo yelp yesterday and has noticed wasps and thinks he might have been stung) - prone to allergic skin reactions, hives, rash.
LABWORK
CBC
WBC 11,300 ; lymphopenia (560)
Manual Hct 51%
PP 5.4
CHEM
Ca++ slt decr 1.92 (N=1.98-3.00 mmol/L)
Liver and renal values normal
TP low normal @ 52
Na+ decr @ 127 (N=144-160 mmol/L)
K+ decr @ 3.0 (N=3.5-5.8 mmol/L)
Cl low @ 99 (N= 109-122)
UA
USG 1.016 (sample collected in our hospital after he received IVF at referring clinic)
pH 8.0
sediment benign
no glucose or protein in urine
iSTAT
pH 7.406
HCO3 22.6
pCO2 36.0
Lytes also low on iSTAT
urea 3.57 (normal)
gluc was 1.925 (N= 4.11-7.95 mmol/L)
BE -2
Labwork shows normal pH with normal HCO3 and pCO2. All lytes below normal.
Lymphopenia
Ca++ slt low
USG 1.016
Repeated iSTAT 4.5 hours after admit; showed normal Na+ and Cl- with K+ just slightly below normal. Glucose normal. pH still normal.
**Has been producing lg amounts urine since admitted (~1750 mls in 5.5 hours = 10 ml/kg/hr 5-10x normal rate) - we have a urinary catheter in.
Continues to start to vocalize when not sedated on CRI meds - less vocal but whining and restless, stumbling - he is possibly less painful now (if he even was painful) but hard to assess due to altered consciousness (and I have never seen him pre-sedation/analgesia)
ASSESSMENT
Acuteness of onset suggest toxin - not many things cause hypoglycemia. Aside from medical issues such as insulinoma and severe hepatic disease (for both of which there is no history suggestive of these, no liver abn on labwork so far) - hypoglycemia not commonly seen with trauma, nor allergic reactions. Xylitol could cause hypoglycemia, diabetic meds (ie: oral anti-hyperglycemics) could cause. Not really anything else. No history of any of these but was off leash.
Allergic reaction could be a coincidental issue?
RHL lameness could be a secondary injury if Leo stumbled and hurt himself once he started being weak?
I'm not sure what is causing the polyuria. He may have received a large amount of fluids at the referring clinic but he was not there that long.
He is being maintained on a CRI of dexdomitor which is keeping him sleeping. Without it he is vocalizing and stumbling all over, agitated. Because he seemed painful at referring clinic and on palpation of RHL we have him on a fentanyl CRI as well. We are slowly tapering both down. When we tapered the DDM CRI too fast he woke up, initially was quiet and alert in sternal but then started to vocalize and stumble and fall around, wouldn't settle. We are planning on doing the orthogonal views of the thorax and the abdomen (VD views).
Does anyone have any brilliant ideas to pull all these things together, any suggestions for further workup or treatment?
☼ | Plt count okay? | Is there cigarette smoking in the home and does the client use room deodorants, carpet fresheners, or burn candles or incense? |
Hello,
I have a puzzling case that I haven't been able to put all the various pieces together yet. I was hoping to tap into the collective brilliance of VIN.
We were presented with an acutely ill 3 year old pitbull. He was initially seen at a local clinic and then sent down to our emergency hospital, seen by a colleague and then transferred to me about 1 hour later for overnight care. The dog was initially ambulatory but came into our clinic non-ambulatory and I first saw him only after he had been given analgesia and sedation so I have never seen him un-sedated. I've written a summary of the information from the referring vet and what we've seen so far.
Leo seemed fine earlier today. He was with owner and very active, playing at local lake - not seen to have got into anything but was off leash and out of sight in bushes several times
Started to act odd, weak, looked gray, piloerection noted at some point along back.
Brought to local clinic and looked shocky, hypothermic (34.7oC, normal is 38.0-39oC) treated with IVF, seemed hunched and seemed unable to use RHL.
Frayed bloody nail on 5th digit RHL
Given analgesia (butorphanol)
Lateral rads taken at referring clinic showed aerophagia, poss FB in stomach (could be piece of rubber toy he was chewing last week). Some patchy mottling of mid to caudal lung fields (still need orthogonal views to assess further)
Came in to our clinic non-ambulatory, still hypothermic but improving,
Less shocky after IVF support, vitals improved, pink MM, temp normalized, HR and BP OK to increased
Started to vocalize and seem mentally altered
HR 120, BP 150
Hypoglycemic (1.9 mmol/L, normal is 4.11-7.95)
Given dextrose IV, K+ added to IVF, butorphanol repeated
Continued to vocalize loudly and be agitated, given alfaxolone IV which worked but didn't last long.
Seemed painful with palpation of RHL even while sedate.
Some dermatitis over legs and ventral body - these areas seemed to get more hyperemic between 18:30 and 19:30 (90 minutes of presentation to our clinic). According to owners he is prone to this, very reactive to many things, usually responds to anti-histamine and a steroid cream.
Bull's eye lesion found near right axilla (owner saw Leo yelp yesterday and has noticed wasps and thinks he might have been stung) - prone to allergic skin reactions, hives, rash.
LABWORK
CBC
WBC 11,300 ; lymphopenia (560)
Manual Hct 51%
PP 5.4
CHEM
Ca++ slt decr 1.92 (N=1.98-3.00 mmol/L)
Liver and renal values normal
TP low normal @ 52
Na+ decr @ 127 (N=144-160 mmol/L)
K+ decr @ 3.0 (N=3.5-5.8 mmol/L)
Cl low @ 99 (N= 109-122)
UA
USG 1.016 (sample collected in our hospital after he received IVF at referring clinic)
pH 8.0
sediment benign
no glucose or protein in urine
iSTAT
pH 7.406
HCO3 22.6
pCO2 36.0
Lytes also low on iSTAT
urea 3.57 (normal)
gluc was 1.925 (N= 4.11-7.95 mmol/L)
BE -2
Labwork shows normal pH with normal HCO3 and pCO2. All lytes below normal.
Lymphopenia
Ca++ slt low
USG 1.016
Repeated iSTAT 4.5 hours after admit; showed normal Na+ and Cl- with K+ just slightly below normal. Glucose normal. pH still normal.
**Has been producing lg amounts urine since admitted (~1750 mls in 5.5 hours = 10 ml/kg/hr 5-10x normal rate) - we have a urinary catheter in.
Continues to start to vocalize when not sedated on CRI meds - less vocal but whining and restless, stumbling - he is possibly less painful now (if he even was painful) but hard to assess due to altered consciousness (and I have never seen him pre-sedation/analgesia)
ASSESSMENT
Acuteness of onset suggest toxin - not many things cause hypoglycemia. Aside from medical issues such as insulinoma and severe hepatic disease (for both of which there is no history suggestive of these, no liver abn on labwork so far) - hypoglycemia not commonly seen with trauma, nor allergic reactions. Xylitol could cause hypoglycemia, diabetic meds (ie: oral anti-hyperglycemics) could cause. Not really anything else. No history of any of these but was off leash.
Allergic reaction could be a coincidental issue?
RHL lameness could be a secondary injury if Leo stumbled and hurt himself once he started being weak?
I'm not sure what is causing the polyuria. He may have received a large amount of fluids at the referring clinic but he was not there that long.
He is being maintained on a CRI of dexdomitor which is keeping him sleeping. Without it he is vocalizing and stumbling all over, agitated. Because he seemed painful at referring clinic and on palpation of RHL we have him on a fentanyl CRI as well. We are slowly tapering both down. When we tapered the DDM CRI too fast he woke up, initially was quiet and alert in sternal but then started to vocalize and stumble and fall around, wouldn't settle. We are planning on doing the orthogonal views of the thorax and the abdomen (VD views).
Does anyone have any brilliant ideas to pull all these things together, any suggestions for further workup or treatment?
☼ | Previous hx of exposure to rodenticides? | What about vaccinations? |
I have a client asking this question. We see their 10 yr CM Scotty Wt 14.1kg. A little background: dxd Diabetes Mellitus July 2011. Became our client Jan 2012. Cataract sx done by specialist March 2012. July 2012 dxd Sudden Aquired Retinal Degeneration. Pet was started on Cyclosporine 100 mg sid, but did not tolerate it (constant diarrhea). Then he was switched to Leflunomide 40 qod and has tolerated the med well. Owner read on human side that the Leflunomide can cause Lymphoma. Are there any reports of that occuring in dogs--or other neoplasias? Any other long term concerns for this dog being on Leuflunomide? (these client wor alot) | Derm or ophtho? | Any reason you don't have him on pred at this time? |
I am not sure if this is the right folder to post this in, but I have a client with a 12 year old nm mixed breed terrier that is 27 pounds. He is a new patient at my clinic. I just recently diagnosed him with diabetes and am still attempting to find the right dose of insulin. He has a history of expiratory dyspnea. The owner always attributed it to allergies at it seems to flare up at certain times of the year. They had previously given him prednisone when he had a flare up, but now with the diabetes I have asked them not to use this. The pred did seem to help. He presented to the hospital yesterday following a night of respiratory distress. The owners reported that he would not settle down, seemed more comfortable sitting, and was panting and drooling heavily. He produced a high pitched noise on expiration. The sound seems like it coming from his laryngeal area and not the chest. I am suspicious of laryngeal paralysis although the breed and size seems a bit odd. On auscultation his chest sounds fine. I took radiographs of the cervical area and thorax. These were reviewed by a radiologist who said the cervical film was normal. The heart and lungs are normal, but there is a narrowing of the trachea just cranial to the tracheal bifurcation.
My questions are:
1. Can a narrowed thoracic trachea cause a high pitched expiratory stridor?
2. Would a bronchodilator have any effect on the trachea in this area?
3. Once his diabetes is better regulated I intend to refer him to have the larynx evaluated but until then I am trying to manage potential laryngeal paralysis medically. I placed him on deramaxx and sent him home with alprazolam for when he was distressed. Unfortunately he appears to be one of those dogs that has paradoxical excitation on the alprazolam. Can you recommend any other medications to help with his anxiety during these episodes?
Thanks | Can you auscultate the larygo-tracheal region and isolate where you hear this the loudest? | Has the alphatrak been checked for accuracy? |
I need help with a 12 month old indoor only cat this presented this morning. Severely dehydrated, temperature 94. Some vomiting. Owner says the cat is vaccinated and other cats in the household are fine. Blood work has me slightly confused:
HCT-46
WBC-23.22
Neu-16.05
Mono-1.87
PLT->32
BUN>130
Crea-2.2 - after dilution
PHOS-11.2
CA1
TBIL-2.3
Na-127
K>10
Cl-100
FeLv/FIV-neg
Owner wants to euthanize if odds are 50% | Is the cat bradycardic? | This sounds like vestibular ataxia, any head tilt and/or positional nystagmus? |
I need help with a 12 month old indoor only cat this presented this morning. Severely dehydrated, temperature 94. Some vomiting. Owner says the cat is vaccinated and other cats in the household are fine. Blood work has me slightly confused:
HCT-46
WBC-23.22
Neu-16.05
Mono-1.87
PLT->32
BUN>130
Crea-2.2 - after dilution
PHOS-11.2
CA1
TBIL-2.3
Na-127
K>10
Cl-100
FeLv/FIV-neg
Owner wants to euthanize if odds are 50% | Is the cat hypoproetinic (hypoalbuminemic)? | Can i see a couple of the curves before this one at 4.5 units bid? |
Spunky is an 11 y/o MN DSH. He was presented in early April for PU/PD, we ran a senior panel with UA, which had the following abnormalities: Serum glucose (H) 25.7 mmol/L; Chloride (L) 108 mmol/L; Calculated Osm (H) 320; USG 1.018, Glucose 56.
We diagnosed him with diabetes and sent home Purina DM the next day and ordered in insulin and set up a diabetes appointment. His inital dose of insulin was 2 U BID. He started eating the DM no problem and the O's scheduled a glucose curve for 3 weeks into treatment. He was 8.6lbs at presentation and the same today.
The glucose curve was last Friday, the O's gave breakfast and 2U insulin at home, then brought him to the clinic, his 9am glucose reading was 25.8 mmol/L and at 11am it was 29.6 mmol/L. We stopped the curve at this point and sent Spunky home with a new dose of insulin, 4U BID.
He came in first thing this morning with the O's reporting that he was stumbling around and acting blind, he also seemed very weak in the hind end and was vomiting last night. He had no insulin today. We checked his BG this morning and it was 4.7 mmol/L. We offered him DM which he ate voraciously and a physical exam showed some hind end weakness and very sluggish PLR and menace, the rest of the exam was WNL. We have done a curve on him today without giving insulin and his BG has continued to climb. 8:45am - 4.7; 10am - 8.4; 12:30pm - 14.9 and 2:30 - 18.2 mmol/L. His PLR's have improved, but his menace is still slow, although he seems to have vision (looks at you when you walk into the kennel room).
My questions are as follows. Was last week's glucose curve showing symogi? Or was 2U BID not enough and 4U BID too much? Should I try 3U BID? Any other suggestions? Could he be starting to go into remission?
Any suggestions are much appreciated. These owners are extremely compliant, but money is a bit of a concern. | It's really a good idea when they're on canned dm (is that all he eats is the canned version? | The owner moves the injections around on his body every day? |
12 year old MN min poodle. weight 10 kg. PMH significant for thyroid carcinoma removed 1 year ago - per pathologist aggressive and not clear margins. Owner elected not to pursue chemotherapy or radiation therapy. Also mild collapsing trachea. Owner is very intense and often non compliant, as he changes the meds to suit himself - he was a medic in Viet Nam, but really cares about this little guy.
Placed on soloxine and calcitriol post op and monitored monthly - results have been normal. Has had mildly elevated ALP, and I was suspicious he may be heading towards Cushings - US showed normal adrenals, but enlarged hyperechoic liver in early April. Have been battling mildly elevated BUN, but owner feeds a ton of meat - dog eats better than I do. Creatinine and USG have always been normal.
Current medications: Soloxine 0.15 BID, Calcitriol 75ng BID, denamarin, omega 3 FA and hydrocodone prn for coughing.
He presented with adr on April 16. Not wanting to do steps and not wanting to eat. Had severely swollen ear canal AS with yeast on gm stain and very painful on palpation of LS spine with delayed CPs of hind limbs. Rads showed spondylsis of L4-5 and L5-6. I started him on ketoconazole otic meds, prednisone 2.5 mg BID for 3, SID for 3 and EOD for 3, mainly to get the swelling down in the ear and for possible IVDD. Also started on tramadol and robaxin.
Owner requested blood work - here are the significant values.
BG 123 (60-125)
BUN 36 (7-27)
ALT 187 (5-107)
ALP 620 (10-150) T4 206
USG 1.050
He dramatically improved in a few days. I rechecked him on 4/30 - and owner requested I repeat his blood work.
BG 307, BUN 41, ALT 241, ALP 1478, Ca ++ 13.5 (8.2-12.4)
Per owner not PU/PD and I was not convinced he was diabetic. Held calcitriol for 24 hours, discussed ALP may be due to prednisone,glucose less likely. suggested fasting BG in 2 days. Owner could not wait - BG next am 335 (70-143) and calcium 11.4 (7.9-12) 3+ glucose on dipstick. Owner thinks he is drinking more.
I still am not convinced - so repeat all bloodwork next day
BG 431
BUN 47
ALT 171
ALP 1072
T4 1.9
USG 1.026 with bacteria seen
Owner measured water consumption and calculates to >100 ml/kg/day.
Also did a LDDS, pre 23.1, 4 hour 1.1, 8 hour 1.3, inconclusive.
spoke with internist, recommended starting on insulin - I did 2 units NPH bid. Had owner come in 2 days after starting insulin to check BG just to make sure not hypoglycemic - 4 hours post insulin 158 mg/dL, my colleague did not change his dose.
because of bacteria, I also started cephalexin 250 bid, awating his urine culture.
Well owner is waiting for me when I get to work this morning. Dog is having tremors, similar to when he was hypocalcemic post op - gave extra dose of calcitriol and gave him honey.
this am BG is 190, but had not gotten insulin since Sunday evening, urine glucose negative, culture negative.
Calcium 8.1. I decreased his insulin to 1 unit and will be checking a glucose in 2 days. Owner has instructions to hold insulin if he seems lethargic and inappetent.
Could this dog be teetering on becoming a diabetic and the prednisone pushed him over into transient hyperglycemia? I watched him all day, and he did have one episode of spastic tremoring that lasted maybe 10 seconds. Otherwise he was normal and I am thinking the tremors are calcium related.
None of the internal medicine people at the lab have had a case like this and I sure would appreciate someones input.
Thanks | What dose of calcitriol was he on when the calcium was 13.5? is the calcitriol being given bid, each dose with food? | One big advantage of being a practice owner with a really profitable practice is that i get to choose how i practice and who i will accept as a client.arnt? |
12 year old MN min poodle. weight 10 kg. PMH significant for thyroid carcinoma removed 1 year ago - per pathologist aggressive and not clear margins. Owner elected not to pursue chemotherapy or radiation therapy. Also mild collapsing trachea. Owner is very intense and often non compliant, as he changes the meds to suit himself - he was a medic in Viet Nam, but really cares about this little guy.
Placed on soloxine and calcitriol post op and monitored monthly - results have been normal. Has had mildly elevated ALP, and I was suspicious he may be heading towards Cushings - US showed normal adrenals, but enlarged hyperechoic liver in early April. Have been battling mildly elevated BUN, but owner feeds a ton of meat - dog eats better than I do. Creatinine and USG have always been normal.
Current medications: Soloxine 0.15 BID, Calcitriol 75ng BID, denamarin, omega 3 FA and hydrocodone prn for coughing.
He presented with adr on April 16. Not wanting to do steps and not wanting to eat. Had severely swollen ear canal AS with yeast on gm stain and very painful on palpation of LS spine with delayed CPs of hind limbs. Rads showed spondylsis of L4-5 and L5-6. I started him on ketoconazole otic meds, prednisone 2.5 mg BID for 3, SID for 3 and EOD for 3, mainly to get the swelling down in the ear and for possible IVDD. Also started on tramadol and robaxin.
Owner requested blood work - here are the significant values.
BG 123 (60-125)
BUN 36 (7-27)
ALT 187 (5-107)
ALP 620 (10-150) T4 206
USG 1.050
He dramatically improved in a few days. I rechecked him on 4/30 - and owner requested I repeat his blood work.
BG 307, BUN 41, ALT 241, ALP 1478, Ca ++ 13.5 (8.2-12.4)
Per owner not PU/PD and I was not convinced he was diabetic. Held calcitriol for 24 hours, discussed ALP may be due to prednisone,glucose less likely. suggested fasting BG in 2 days. Owner could not wait - BG next am 335 (70-143) and calcium 11.4 (7.9-12) 3+ glucose on dipstick. Owner thinks he is drinking more.
I still am not convinced - so repeat all bloodwork next day
BG 431
BUN 47
ALT 171
ALP 1072
T4 1.9
USG 1.026 with bacteria seen
Owner measured water consumption and calculates to >100 ml/kg/day.
Also did a LDDS, pre 23.1, 4 hour 1.1, 8 hour 1.3, inconclusive.
spoke with internist, recommended starting on insulin - I did 2 units NPH bid. Had owner come in 2 days after starting insulin to check BG just to make sure not hypoglycemic - 4 hours post insulin 158 mg/dL, my colleague did not change his dose.
because of bacteria, I also started cephalexin 250 bid, awating his urine culture.
Well owner is waiting for me when I get to work this morning. Dog is having tremors, similar to when he was hypocalcemic post op - gave extra dose of calcitriol and gave him honey.
this am BG is 190, but had not gotten insulin since Sunday evening, urine glucose negative, culture negative.
Calcium 8.1. I decreased his insulin to 1 unit and will be checking a glucose in 2 days. Owner has instructions to hold insulin if he seems lethargic and inappetent.
Could this dog be teetering on becoming a diabetic and the prednisone pushed him over into transient hyperglycemia? I watched him all day, and he did have one episode of spastic tremoring that lasted maybe 10 seconds. Otherwise he was normal and I am thinking the tremors are calcium related.
None of the internal medicine people at the lab have had a case like this and I sure would appreciate someones input.
Thanks | What dose of calcitriol did you restart after you withheld it for 24 hours? | Does she sit and tremble like that all the time? |
I have a 4 1/2 year old m/n dsh who I saw back in October for an annual visit. The cat is indoors only except for rare occasions when he escapes in the yard then scurries back inside. He was a stray from my clinic that the owner adopted around 6-8 months old. The owner reported no concerns, but I noted the cat lose weight from 12 pounds the year before to 9 pounds 12 oz. PE unremarkable. No GI signs. CBC, chem, UA, T4 were unremarkable. Fecal float was negative. The owner then declined further workup until the end of January. Weight now 9 pounds 2 oz. Thoracic and abd rads were unremarkable. FELV/FIV negative. The owner then waited until April before pursuing further testing. In April 8 pounds 13 oz. USG 1.050 TP 6.8. Still no clinical signs.
cobalamin 150 (290-1500)
folate normal at 13.2 (9.7-21.6)
TLI normal at 48.9 (12-82)
PLI 17.3 (0.1-3.5)
The owner declined repeating chems. Owner declined GI endoscopy or exlap.
I started the cat on Royal Canin PD (peas and duck) and cobalamin injections on 4/18 (owner to switch over a week) and metronidazole compounded at Roadrunner Pharmacy in vanilla butternut liquid (started 4/24). The cat hates the metronidazole. The owners are having a hard time giving it. And now the cat has diarrhea. What should I do now? | Is he a finicky eater? | What are your lab normals? |
Hello, I am posting about a case which I am finding tricky. I have not had many diabetic cases personally and am such am after some advice. Please forgive this ridiculously long post.
Max is a 6.4kg, 10 year old MN Maltese. I originally saw Max for uveitis back in December '12. He was placed on Maxidex drops, they originally improved, then regressed. He was seen by a veterinary ophthalmologist who confirmed the diagnosis of uveitis and placed Max on pred forte drops TID, oral pred (10mg SID for 14d, 5mg SID for 5d, then EOD for a further 7 treatments), doxycyline 50mg BID for 14 days. Max responded well.
24/1/12 - At this time we also performed a blood test to ensure no underlying abnormalities. The results are as follows
ALT 193 (80)
GGT 12 ( 6)
ALP 994 (1-120)
Protein 65 (55-78)
Alb 39 (22-36)
Lipase 206 (0-70)
CPLi abnormal
Rest of the bloods results (biochem and haematology wnl)
5/2/13: After consulting with ophthalmologist we dosed Max at 0.5mg/kg SID pred for two weeks and continued doxycyline for 4 weeks.
22/3/13: Back to ophthalmologist who diagnosed mature cataracts, said surgery was not an option as eyes had low intraocular pressure. Continue pred forte drops TID, stop systemic pred.
9/4/13: Max presented PU/PD. In house BG showed reading of 29.9.
At this stage Max was still on 5mg pred EOD.
Full bloods below:
WCC 14.1 (6-14)
Neut 11.4 (4.1-9.4)
Lymp 0.6 (0.9-3.6)
Mono 2 (0.2-1.0)
K 6.8 (3.8-5.8)
Glu 27.4 (3.5-6.7)
ALT 115 (80)
GGT 69 (6)
ALP 904 (1-120)
Alb 43 (22-36)
Glob 23 (25-40)
Phos 2.17 (0.8-2)
Rest wnl
Systemic pred therapy stopped, pred forte drops decreased to SID.
11/4/13: Started Max on Caninsulin 3iu (0.5iu/kg) BID.
19/4/13: BG curve
8am - 32.4
10am - 27.5
12pm - 31.5
2pm - 32.5
4pm - 27.2
530pm - 30.6
Increased to 4 iu BID.
26/4/13: BG curve
0815 - 17.5
1015 - 14.1
1215 - 26.1
1415 - 30.2
1615 - 29.8
Increased to 5iu caninsulin BID
3/5/13:
Clinically max is going a lot better, his PU/PD is settling.
BG Curve
0815 - 26.4
1015 - 22.4
1215 - 27.5
1415 - 31.2
1615 - high
I was very disappointed with this curve as I thought we were making progress. I had also considered the possibility of hyperA in this dog as he had increased ALP, thinning coat, pot-belly, panting, PU/PD, polyphagic. As such on the 3/5/13 I also performed an ACTH stimulation test.
0 hour cortisol 24
1 hour cortisol 215
This was NOT consistent with a diagnosis of hyperA which I was very surprised by.
So finally, I reach my question....do I just keep gradually increasing his Caninsulin 1 unit at a time? I felt I was making progress and then went backwards - is this something to be expected? Am I missing something? These are very committed and lovely owners and I would like to try to get them some good results for Max. And doing a weekly curve is getting expensive for them (although high cost of conditions like this was explained at time of diagnosis, it is still difficult to pay for this each week without getting results).
Thank you very much in advance,
☼ | I'd check with the ophthalmologist about whether you could use another steroid for the eyes (hydrocortisone only is good for corneal disease, so we're talking about dex...the dex ointment is less systemically-absorbed than the drops)....or, even better if it's ok for the eyes, could we please switch to a nsaid for the eyes? | Is there any restriction to airflow in one or both nasal passages? |
Hello, I am posting about a case which I am finding tricky. I have not had many diabetic cases personally and am such am after some advice. Please forgive this ridiculously long post.
Max is a 6.4kg, 10 year old MN Maltese. I originally saw Max for uveitis back in December '12. He was placed on Maxidex drops, they originally improved, then regressed. He was seen by a veterinary ophthalmologist who confirmed the diagnosis of uveitis and placed Max on pred forte drops TID, oral pred (10mg SID for 14d, 5mg SID for 5d, then EOD for a further 7 treatments), doxycyline 50mg BID for 14 days. Max responded well.
24/1/12 - At this time we also performed a blood test to ensure no underlying abnormalities. The results are as follows
ALT 193 (80)
GGT 12 ( 6)
ALP 994 (1-120)
Protein 65 (55-78)
Alb 39 (22-36)
Lipase 206 (0-70)
CPLi abnormal
Rest of the bloods results (biochem and haematology wnl)
5/2/13: After consulting with ophthalmologist we dosed Max at 0.5mg/kg SID pred for two weeks and continued doxycyline for 4 weeks.
22/3/13: Back to ophthalmologist who diagnosed mature cataracts, said surgery was not an option as eyes had low intraocular pressure. Continue pred forte drops TID, stop systemic pred.
9/4/13: Max presented PU/PD. In house BG showed reading of 29.9.
At this stage Max was still on 5mg pred EOD.
Full bloods below:
WCC 14.1 (6-14)
Neut 11.4 (4.1-9.4)
Lymp 0.6 (0.9-3.6)
Mono 2 (0.2-1.0)
K 6.8 (3.8-5.8)
Glu 27.4 (3.5-6.7)
ALT 115 (80)
GGT 69 (6)
ALP 904 (1-120)
Alb 43 (22-36)
Glob 23 (25-40)
Phos 2.17 (0.8-2)
Rest wnl
Systemic pred therapy stopped, pred forte drops decreased to SID.
11/4/13: Started Max on Caninsulin 3iu (0.5iu/kg) BID.
19/4/13: BG curve
8am - 32.4
10am - 27.5
12pm - 31.5
2pm - 32.5
4pm - 27.2
530pm - 30.6
Increased to 4 iu BID.
26/4/13: BG curve
0815 - 17.5
1015 - 14.1
1215 - 26.1
1415 - 30.2
1615 - 29.8
Increased to 5iu caninsulin BID
3/5/13:
Clinically max is going a lot better, his PU/PD is settling.
BG Curve
0815 - 26.4
1015 - 22.4
1215 - 27.5
1415 - 31.2
1615 - high
I was very disappointed with this curve as I thought we were making progress. I had also considered the possibility of hyperA in this dog as he had increased ALP, thinning coat, pot-belly, panting, PU/PD, polyphagic. As such on the 3/5/13 I also performed an ACTH stimulation test.
0 hour cortisol 24
1 hour cortisol 215
This was NOT consistent with a diagnosis of hyperA which I was very surprised by.
So finally, I reach my question....do I just keep gradually increasing his Caninsulin 1 unit at a time? I felt I was making progress and then went backwards - is this something to be expected? Am I missing something? These are very committed and lovely owners and I would like to try to get them some good results for Max. And doing a weekly curve is getting expensive for them (although high cost of conditions like this was explained at time of diagnosis, it is still difficult to pay for this each week without getting results).
Thank you very much in advance,
☼ | Can we teach the owners to generate the bg curves at home? | How long has she been on the prednisone now? |
Hello,
I got passed this case today, and I was wondering if I could have some insight.
I did not admit the cat, so am lacking a bit of history, so apologies for that.
Dom is a 14 year old cat that presented today weak, lethargic and jaundiced (even his skin is yellow is places!)
I don't think I've ever seen a cat quite so jaundiced.
weighs 3.4kg, and hasn't been eating for last 2-3 days
Admitted for IVFT and bloods
Bloods show the following:
Biochem:
ALB 28g/L (N:23-39)
ALKP +488U/L (N:14-111)
ALT +768U/L (N:12-130)
AMYL 1111U/L (N:500-1500)
UREA +43.2mmol/L (N:5.7-12.9)
Ca 2.48mmol/L (N:1.95-2.83)
CREA +227umol/L (N:71-212)
GLOB +70g/L (N:28-51)
GLU +>38.11mmol/L (N:3.94-8.83)
LIPA 870U/L (N:100-1400)
PHOS 2.23mmol/L (N:1.00-2.42)
TBIL +477umol/L (N:0-15)
TP +98g/L (N:57-89)
haem:
HCT 27.8% (N:24-45)
HGB 9.6g/dL (N:8-15)
MCHC 34.5g/dL (N:30-36.9)
WBC +22.2x10*9/L (N:5.0-18.9)
GRANS +17.1x10*9/L (N:2.5-12.5)
%GRAN 77%
L/M 5.1x10*9/L (N:1.5-7.8)
%L/M 23%
PLT >760x10*9/L (N:175-500)
I'm thinking that the normal HCT/MCHC rules out hemolytic anemia as a cause for the jaundice
Its the biochem that's getting me confused.
The bilirubin through the roof - does this mean that there is an obstruction/stasis to bile duct flow?
And then the glucose is so high it's immeasurable - could there be a primary diabetes here, or is it more likely to be a secondary issue?
Because of the jaundice and highish liver values, is primary cholangitis likely to be the main problem?
I'm assuming the platelets are high because cats platelets clot
For now the cat is receiving supportive care, the owners don't have much money (usual story)
Cat doesn't seem to have ever been vaccinated, no travel history, no worming history, no history really! (apologies)
I think it will end up being a PTS :( as owners don't have funds for further investigation, and cat doesn't seem to be responding much to initial therapy (albeit just IVFT, pain relief, and antibiotics)
If someone else could just advise me on what they think of the bloods? Do my interpretations seems ok? I'm confused as to what is secondary and what could be primary problems I think
Havent got urine yet as bladder was empty, but planning on it.
Thanks. | How were his electrolytes? | Any chance you got an additional urine sample as well to see how the urine appears today? |
My patient is an eight year old spayed female Yorkshire Terrier. She is diabetic and reasonably well controlled with a most recent Fructosamine of 492 umol/L. Her triglycerides initially were 3421 mg/dl. The veterinary ophthalmologist wants her triglycerides down before cataract surgery can be considered. We have had her on Gemfibrizol with little improvement in triglycerides.
What else can we do? The owner is feeding a low fat diet. | Were those triglycerides run after a 12 hour fast? | Was the crystalluria seen in a urine sample read 15-30 minutes after collection by cystocentesis? |
My patient is an eight year old spayed female Yorkshire Terrier. She is diabetic and reasonably well controlled with a most recent Fructosamine of 492 umol/L. Her triglycerides initially were 3421 mg/dl. The veterinary ophthalmologist wants her triglycerides down before cataract surgery can be considered. We have had her on Gemfibrizol with little improvement in triglycerides.
What else can we do? The owner is feeding a low fat diet. | Is that what she's on? | How are the dog's clinical signs doing with respect to pu/pd, weight stability, etc? |
Hello....help with a plan in this case would be great.
10 yo MN 11 pound maltese
Internist ultrasound on 4-3/13 diagnosed diabetes mellitus, pancreatitis, possible pyelonephririts of the left kidney, cholelithiasis, possible cushings (pdh)
Been a tough case.....almost passed....was ketoacidotic, etc.....but finally doing quite well...almost back to his old self. Did a long course of clavamox and baytril...also had on vitamin k for a while, was also on ursodiol.
BG curves have been difficult/high....finally got a great curve last week. Currenlty on 8 units of NPH Q 12 hours. Owners feeding wellness food...and being good about only BID. Tried w/d, but he prefers his regular food.
Actually had pretty much a perfect curve last week....initial glucose 130, nadir was 80...right at 6 hours later.
However.......I noticed calcinosis cutis along ingunial and axilla last week.
Therfore I did an ACTH stim, and was 6.6 initial, and 42.2 post cortrysn (8-17 normal post)
Currently on 8 units NPH BID and his regular food BID. Getting close to resistance, but was a good curve.
I need to start vetoryl (trilostane)
I see where a good dose for his size is 5 mg BID (1 mg/kg BID dose)
Can you help me with a plan? Keeping in mind that I now have some financial constraints....kind of let them build up the bill since there always seems to be something else with this dog...yet he pulls through.
I am having a hard time figuring out how I should go about decreasing his high insulin dose....now that we will statr trilostane. Is there a graph?
Do I do something like drop his insulin by 25% when I start trilostane?
Get a curve in one week?
Then get an ACTH stim (3-5 hrs after am capsule) and curve a week after that?
Although he is doing well now, I feel that I have to recommend treating the cushings.
Thanks
☼ | Plus it sounds like he had bilateral adrenomegaly on the ultrasound? | Are they shaking the vetsulin as directed or gently rolling? |
My patient is an 11 year old diabetic cat who had been previously very well controlled with low doses of Prozinc and a low carb canned diet. He was diagnosed as hyperthyroid in 3 months ago, and ever since we started him on methimazole, his diabetes regulation has been steadily declining. He has some moderate oral tartar and gingivitis, and his last UA showed no signs of cystitis.
We have yet to check for pancreatitis, but his owner is starting to feel the pinch from all the testing and monitoring we have been doing.
What I have not yet mentioned is that in the interest of saving money, I agreed to let the owner to purchase the methimazole from an online pharmacy. Today, I read the package insert for the specific product she has been purchasing. It appears to be a human formulation, and contains not only 5 mg of methimazole, but also lactose monohydrate, corn starch, and Mg stearate and talc. Could there be enough lactose in these pills to be throwing his diabetes off? I will also post this to the pharmacy boards as well.
Thank you! ☼ | Is it his clinical signs that have changed or his bgs? | How leukopenic was she? |
My patient is an 11 year old diabetic cat who had been previously very well controlled with low doses of Prozinc and a low carb canned diet. He was diagnosed as hyperthyroid in 3 months ago, and ever since we started him on methimazole, his diabetes regulation has been steadily declining. He has some moderate oral tartar and gingivitis, and his last UA showed no signs of cystitis.
We have yet to check for pancreatitis, but his owner is starting to feel the pinch from all the testing and monitoring we have been doing.
What I have not yet mentioned is that in the interest of saving money, I agreed to let the owner to purchase the methimazole from an online pharmacy. Today, I read the package insert for the specific product she has been purchasing. It appears to be a human formulation, and contains not only 5 mg of methimazole, but also lactose monohydrate, corn starch, and Mg stearate and talc. Could there be enough lactose in these pills to be throwing his diabetes off? I will also post this to the pharmacy boards as well.
Thank you! ☼ | Have we made sure he doesn't also now have ckd? | Do you think the octreotide is doing anything for the hypoglycemia? |
My patient is an 11 year old diabetic cat who had been previously very well controlled with low doses of Prozinc and a low carb canned diet. He was diagnosed as hyperthyroid in 3 months ago, and ever since we started him on methimazole, his diabetes regulation has been steadily declining. He has some moderate oral tartar and gingivitis, and his last UA showed no signs of cystitis.
We have yet to check for pancreatitis, but his owner is starting to feel the pinch from all the testing and monitoring we have been doing.
What I have not yet mentioned is that in the interest of saving money, I agreed to let the owner to purchase the methimazole from an online pharmacy. Today, I read the package insert for the specific product she has been purchasing. It appears to be a human formulation, and contains not only 5 mg of methimazole, but also lactose monohydrate, corn starch, and Mg stearate and talc. Could there be enough lactose in these pills to be throwing his diabetes off? I will also post this to the pharmacy boards as well.
Thank you! ☼ | Do you mind posting some of his recent blood work? | Whether to consider a water deprivation test and/or ct or mri are up to the owner--are they going to want to pursue surgery or radiation? |
"Diva" is an 11 yr old 5 kg chihuahua i saw as second opinion for diabetes.owner's main concern is ongoing HUNGER.
dx with dka feb 2011, had previous episode of severe pancreatitis (2008), not sure if she had an ultrasound then. was over weight at time, was on w/d initially, now on low residue or i/d, canned and some dry, some additional protein, hard to tell how many calories she eats from o's description. is NOT pu/pd per o- goes to water bowl several times daily but only moderate intake (different from before dx). gets up at night for food but not to pee, no urinary accidents. o thinks she may do better when she gives her extra protein at dinner. bm is normal. o thinks has acid reflux- gives pepcid which seems to help. o also concerned breath is bad.
has had persistant elevation of alp, baseline cortisol measure in 2011 was wnl. glucose curve last year nadir in 200's (422- 213 at about 6 hrs)
on 4.8 units humulin n insulin bid (0.9 u/kg)
physical exam normal exc or gingivitis and heart murmur. weight is good.
current lab;
cbc wnl
glucose 413
alp 2000
alt283
ur sp gr 1037 2+ glucos, 2+ ketones
fructosamine 29
urine culture negative but o feels improved on pancreatic enzymes and clavamox
persistant ketonuria
acth stim 10-18
i am recommending ultrasound, but assuing i have NOT diagnosed cushings and need to increase insulin dose and be sure owner is handling and injecting insulin normally.
any other reocmmendations? | Am i correct in that the prestimulated cortisol was 10 and the post was 18? | Any signs of problems? |
"Diva" is an 11 yr old 5 kg chihuahua i saw as second opinion for diabetes.owner's main concern is ongoing HUNGER.
dx with dka feb 2011, had previous episode of severe pancreatitis (2008), not sure if she had an ultrasound then. was over weight at time, was on w/d initially, now on low residue or i/d, canned and some dry, some additional protein, hard to tell how many calories she eats from o's description. is NOT pu/pd per o- goes to water bowl several times daily but only moderate intake (different from before dx). gets up at night for food but not to pee, no urinary accidents. o thinks she may do better when she gives her extra protein at dinner. bm is normal. o thinks has acid reflux- gives pepcid which seems to help. o also concerned breath is bad.
has had persistant elevation of alp, baseline cortisol measure in 2011 was wnl. glucose curve last year nadir in 200's (422- 213 at about 6 hrs)
on 4.8 units humulin n insulin bid (0.9 u/kg)
physical exam normal exc or gingivitis and heart murmur. weight is good.
current lab;
cbc wnl
glucose 413
alp 2000
alt283
ur sp gr 1037 2+ glucos, 2+ ketones
fructosamine 29
urine culture negative but o feels improved on pancreatic enzymes and clavamox
persistant ketonuria
acth stim 10-18
i am recommending ultrasound, but assuing i have NOT diagnosed cushings and need to increase insulin dose and be sure owner is handling and injecting insulin normally.
any other reocmmendations? | Did we measure a tli? | Are you sure he's both hypothyroid and cushinoid? |
"Diva" is an 11 yr old 5 kg chihuahua i saw as second opinion for diabetes.owner's main concern is ongoing HUNGER.
dx with dka feb 2011, had previous episode of severe pancreatitis (2008), not sure if she had an ultrasound then. was over weight at time, was on w/d initially, now on low residue or i/d, canned and some dry, some additional protein, hard to tell how many calories she eats from o's description. is NOT pu/pd per o- goes to water bowl several times daily but only moderate intake (different from before dx). gets up at night for food but not to pee, no urinary accidents. o thinks she may do better when she gives her extra protein at dinner. bm is normal. o thinks has acid reflux- gives pepcid which seems to help. o also concerned breath is bad.
has had persistant elevation of alp, baseline cortisol measure in 2011 was wnl. glucose curve last year nadir in 200's (422- 213 at about 6 hrs)
on 4.8 units humulin n insulin bid (0.9 u/kg)
physical exam normal exc or gingivitis and heart murmur. weight is good.
current lab;
cbc wnl
glucose 413
alp 2000
alt283
ur sp gr 1037 2+ glucos, 2+ ketones
fructosamine 29
urine culture negative but o feels improved on pancreatic enzymes and clavamox
persistant ketonuria
acth stim 10-18
i am recommending ultrasound, but assuing i have NOT diagnosed cushings and need to increase insulin dose and be sure owner is handling and injecting insulin normally.
any other reocmmendations? | New curve? | Can you show me her last couple of curves? |
"Diva" is an 11 yr old 5 kg chihuahua i saw as second opinion for diabetes.owner's main concern is ongoing HUNGER.
dx with dka feb 2011, had previous episode of severe pancreatitis (2008), not sure if she had an ultrasound then. was over weight at time, was on w/d initially, now on low residue or i/d, canned and some dry, some additional protein, hard to tell how many calories she eats from o's description. is NOT pu/pd per o- goes to water bowl several times daily but only moderate intake (different from before dx). gets up at night for food but not to pee, no urinary accidents. o thinks she may do better when she gives her extra protein at dinner. bm is normal. o thinks has acid reflux- gives pepcid which seems to help. o also concerned breath is bad.
has had persistant elevation of alp, baseline cortisol measure in 2011 was wnl. glucose curve last year nadir in 200's (422- 213 at about 6 hrs)
on 4.8 units humulin n insulin bid (0.9 u/kg)
physical exam normal exc or gingivitis and heart murmur. weight is good.
current lab;
cbc wnl
glucose 413
alp 2000
alt283
ur sp gr 1037 2+ glucos, 2+ ketones
fructosamine 29
urine culture negative but o feels improved on pancreatic enzymes and clavamox
persistant ketonuria
acth stim 10-18
i am recommending ultrasound, but assuing i have NOT diagnosed cushings and need to increase insulin dose and be sure owner is handling and injecting insulin normally.
any other reocmmendations? | How is the dog's body weight? | The owner can accurately measure and then inject the insulin each time? |
Dear colleagues
I have seen, unfortunately, consequences of steroids in cats (DM, CHF)- not necessarily chronic, nor high dose-my question is- Is a cat w/a murmur at any greater risk of developing CHF from steroids than those w/o. If they do have a greater risk do you echo them before steroids?
☼ | How many cats with murmurs have severe heart disease? | How well controlled is her dm? |
Dear colleagues
I have seen, unfortunately, consequences of steroids in cats (DM, CHF)- not necessarily chronic, nor high dose-my question is- Is a cat w/a murmur at any greater risk of developing CHF from steroids than those w/o. If they do have a greater risk do you echo them before steroids?
☼ | Conversely, how many cats with severe heart disease have murmurs? | Is that the confusion perhaps? |
Dear colleagues
I have seen, unfortunately, consequences of steroids in cats (DM, CHF)- not necessarily chronic, nor high dose-my question is- Is a cat w/a murmur at any greater risk of developing CHF from steroids than those w/o. If they do have a greater risk do you echo them before steroids?
☼ | Does that help? | What about putting a freestyle libre on the dog and seeing what happens as you start the insulin? |
Hello....I have a 9 year old, FS, DSH, 6-7 pound cat who I diagnosed with diabetes in March. The following is what I've done:
3/16/2013: Initial Visit: Full chemistry panel and U/A
*all WNL except glucose was 438 and 3+ glucosuria
3/18/2013: patient started on canned Purina DM and 1 unit Glargine BID
4/4/2013: Glucose curve
Pre-insulin 8:15am: 206
Post insulin 10:20am: 174
12:26: 244
2:30: 277
4:30: 269
**patient kept at 1U BID
4/18/2013 Glucose Curve
Pre-insulin 8:30am: 131
Post Insulin 10:25am: 183
1:00: 148
3:00: 185
**patient kept at 1U BID
5/2/2013 Glucose curve
Pre-insulin 8:26: 101
Post Insluin: 11:00: 45
**fed canned DM
1:15: 60
3:21: 29
**fed max cal
4:25: 68
**I debated and debated about 1U SID or 1/2U SID and decreased the patient to 1/2U SID
Today (5/9/2013): Glucose Curve
Pre-insulin 8:35: 289
Post insluin 10:45: 302
Now I'm kicking myself that I didn't do the 1U SID dose.
The patient shows no clinical signs of hyperglycemia or hypoglycemia.
I am now thinking I need to go up to 1U SID but would love someone's expert opinion. Thanks! | Is there any way that the client can check the bg's at home? | This is a situation where i think it really helps for the owner to learn to generate bg curves at home...any chance of this? |
Hello....I have a 9 year old, FS, DSH, 6-7 pound cat who I diagnosed with diabetes in March. The following is what I've done:
3/16/2013: Initial Visit: Full chemistry panel and U/A
*all WNL except glucose was 438 and 3+ glucosuria
3/18/2013: patient started on canned Purina DM and 1 unit Glargine BID
4/4/2013: Glucose curve
Pre-insulin 8:15am: 206
Post insulin 10:20am: 174
12:26: 244
2:30: 277
4:30: 269
**patient kept at 1U BID
4/18/2013 Glucose Curve
Pre-insulin 8:30am: 131
Post Insulin 10:25am: 183
1:00: 148
3:00: 185
**patient kept at 1U BID
5/2/2013 Glucose curve
Pre-insulin 8:26: 101
Post Insluin: 11:00: 45
**fed canned DM
1:15: 60
3:21: 29
**fed max cal
4:25: 68
**I debated and debated about 1U SID or 1/2U SID and decreased the patient to 1/2U SID
Today (5/9/2013): Glucose Curve
Pre-insulin 8:35: 289
Post insluin 10:45: 302
Now I'm kicking myself that I didn't do the 1U SID dose.
The patient shows no clinical signs of hyperglycemia or hypoglycemia.
I am now thinking I need to go up to 1U SID but would love someone's expert opinion. Thanks! | Have you ruled out, to the best of your ability, any concurrent diseases that may be causing insulin resistance at this time, such as a uti? | Could you try to take the blood pressure readings perhaps out in the parking lot before the dog even enters the clinic? |
Tom is a 6.8 kg MN DSH that was recently diagnosed with diabetes. He presented with initially three weeks ago for pu/pd and decreased energy. At the time we ran a full blood panel(incl. a pli). We started him on tramadol for discomfort, glargine(2 units BID) and famotidine. His diabetes has been relatively easy to control and the owners do most of the testing at home. However, his pli has continued to remain high(most recent value was at 20(with anything above 3.5 as being abnormal) and he just is not himself. I suspect it is his pancreatitis but I am not sure what I can really do about it. I would consider starting steroids, but worry that it may affect his regulation. Would an ultrasound be the next best step? Any thoughts on how I can handle a situation like this? | Was he an overweight cat to begin with? | What has the cat's albumin been like? |
Tom is a 6.8 kg MN DSH that was recently diagnosed with diabetes. He presented with initially three weeks ago for pu/pd and decreased energy. At the time we ran a full blood panel(incl. a pli). We started him on tramadol for discomfort, glargine(2 units BID) and famotidine. His diabetes has been relatively easy to control and the owners do most of the testing at home. However, his pli has continued to remain high(most recent value was at 20(with anything above 3.5 as being abnormal) and he just is not himself. I suspect it is his pancreatitis but I am not sure what I can really do about it. I would consider starting steroids, but worry that it may affect his regulation. Would an ultrasound be the next best step? Any thoughts on how I can handle a situation like this? | How is his bcs? | Would spironolactone be advisable? |
Tom is a 6.8 kg MN DSH that was recently diagnosed with diabetes. He presented with initially three weeks ago for pu/pd and decreased energy. At the time we ran a full blood panel(incl. a pli). We started him on tramadol for discomfort, glargine(2 units BID) and famotidine. His diabetes has been relatively easy to control and the owners do most of the testing at home. However, his pli has continued to remain high(most recent value was at 20(with anything above 3.5 as being abnormal) and he just is not himself. I suspect it is his pancreatitis but I am not sure what I can really do about it. I would consider starting steroids, but worry that it may affect his regulation. Would an ultrasound be the next best step? Any thoughts on how I can handle a situation like this? | How old is he? | Has their glucometer been checked for accuracy? |
Tom is a 6.8 kg MN DSH that was recently diagnosed with diabetes. He presented with initially three weeks ago for pu/pd and decreased energy. At the time we ran a full blood panel(incl. a pli). We started him on tramadol for discomfort, glargine(2 units BID) and famotidine. His diabetes has been relatively easy to control and the owners do most of the testing at home. However, his pli has continued to remain high(most recent value was at 20(with anything above 3.5 as being abnormal) and he just is not himself. I suspect it is his pancreatitis but I am not sure what I can really do about it. I would consider starting steroids, but worry that it may affect his regulation. Would an ultrasound be the next best step? Any thoughts on how I can handle a situation like this? | Has he had a fever at all? | Is there any muscle atrophy? |
Tom is a 6.8 kg MN DSH that was recently diagnosed with diabetes. He presented with initially three weeks ago for pu/pd and decreased energy. At the time we ran a full blood panel(incl. a pli). We started him on tramadol for discomfort, glargine(2 units BID) and famotidine. His diabetes has been relatively easy to control and the owners do most of the testing at home. However, his pli has continued to remain high(most recent value was at 20(with anything above 3.5 as being abnormal) and he just is not himself. I suspect it is his pancreatitis but I am not sure what I can really do about it. I would consider starting steroids, but worry that it may affect his regulation. Would an ultrasound be the next best step? Any thoughts on how I can handle a situation like this? | What was he eating prior to diagnosis, and what's he eating now? | How much should he weigh? |
Tom is a 6.8 kg MN DSH that was recently diagnosed with diabetes. He presented with initially three weeks ago for pu/pd and decreased energy. At the time we ran a full blood panel(incl. a pli). We started him on tramadol for discomfort, glargine(2 units BID) and famotidine. His diabetes has been relatively easy to control and the owners do most of the testing at home. However, his pli has continued to remain high(most recent value was at 20(with anything above 3.5 as being abnormal) and he just is not himself. I suspect it is his pancreatitis but I am not sure what I can really do about it. I would consider starting steroids, but worry that it may affect his regulation. Would an ultrasound be the next best step? Any thoughts on how I can handle a situation like this? | Is he indoor-only? | Bladder wnl - radiodense fimbriated structures seen on rads don't enter bladder - wall - dystrophic calcification? |
Tom is a 6.8 kg MN DSH that was recently diagnosed with diabetes. He presented with initially three weeks ago for pu/pd and decreased energy. At the time we ran a full blood panel(incl. a pli). We started him on tramadol for discomfort, glargine(2 units BID) and famotidine. His diabetes has been relatively easy to control and the owners do most of the testing at home. However, his pli has continued to remain high(most recent value was at 20(with anything above 3.5 as being abnormal) and he just is not himself. I suspect it is his pancreatitis but I am not sure what I can really do about it. I would consider starting steroids, but worry that it may affect his regulation. Would an ultrasound be the next best step? Any thoughts on how I can handle a situation like this? | Is he still on tramadol? | When was the last time you actually saw the cat and were able to do blood and urine tests? |
Hi
I have a 9 yr old nm Chesapeake Bay Retriever who is an uncomplicated diabetic. He is on NPH insulin twice daily. His family is ttesting his blood glucose and has an excellent understanding of DM and insulin function. I would like to change his insulin to Vetsulin because he has an unusual glucose curve on NPH. He takes 16-17 units in the morning and 3-4 units at night. His evening BG's are generally less than 100 even after eating. Morning BG is about 250. We started with 10 units BID and he consistently became hypoglycemic at night. The dose we have now seems to give the best glucose curve. What would you recommend for this 74lb dog regarding vetsulin dose to start? Is there any way to know if vetsulin is here to stay? Thanks for your help.
☼ | If he's doing well on the nph why do you want to switch him? | I think 3 1/2 units is the right dose to try next---can the owner not see well enough or is the owner troubled by the inaccuracy of measuring 1/2 unit where there is no marking? |
Tessa is an 11 year old Beagle mix. She has been severely PU/PD for over a year. I first saw her last year. Initial bloodwork showed USG 1.000, TP 7.8, ALP 771, ALT 167, Trigl 727. Urine sediment was clear. ACTH stim test normal. Recheck USG 1.000. Owner declined further workup and did a trial of Desmopressin. Owner obviously noticed dramatic improvements in PU/PD. She did great through the winter. Now that the weather is warming up, she is hiding more and acting more lethargic. Owner describes disorientated when outside in the heat. She is having some soft stool and her abdomen appears more distended. USG last week while on TID Desmopressin was 1.015. ALP 1588, ALT 150, TP 7.6. Abdominal Ultrasound revealed a moderate amount of sludge in the gallbladder but all else WNL. Baseline cortisol 5.5. I advised the owner to decrease her desmopressin to BID in the summer and he has seen some improvement in her heat tolerance. He is not interested in referral at this time. I am still worried about cushings but realize I would need to more testing. Any other thoughts on where to go from here? Thanks!
R. ☼ | Repeat usgs were also 1.006? | Absolutely sure that she's spayed? |
have a 2 year old DSH FS that presented with PU/PD. Blood glucose is 453, urine glucose is 2000, SPG overnight is 1.040, pH 6.5, 1+ protein. I don't think I have ever seen diabetes in such a young cat. Would you recommend abdominal ultrasound with a situation like this? Thanks. | Any hx of corticosteroid use? | The food/insulin go in at the same time? |
have a 2 year old DSH FS that presented with PU/PD. Blood glucose is 453, urine glucose is 2000, SPG overnight is 1.040, pH 6.5, 1+ protein. I don't think I have ever seen diabetes in such a young cat. Would you recommend abdominal ultrasound with a situation like this? Thanks. | What diet has she been eating? | Were phosphorous and pth-rp levels normal? |
have a 2 year old DSH FS that presented with PU/PD. Blood glucose is 453, urine glucose is 2000, SPG overnight is 1.040, pH 6.5, 1+ protein. I don't think I have ever seen diabetes in such a young cat. Would you recommend abdominal ultrasound with a situation like this? Thanks. | Is she/was she overweight? | What type of medication is it? |
have a 2 year old DSH FS that presented with PU/PD. Blood glucose is 453, urine glucose is 2000, SPG overnight is 1.040, pH 6.5, 1+ protein. I don't think I have ever seen diabetes in such a young cat. Would you recommend abdominal ultrasound with a situation like this? Thanks. | Current bcs? | Is the appetite improved? |
have a 2 year old DSH FS that presented with PU/PD. Blood glucose is 453, urine glucose is 2000, SPG overnight is 1.040, pH 6.5, 1+ protein. I don't think I have ever seen diabetes in such a young cat. Would you recommend abdominal ultrasound with a situation like this? Thanks. | How strongly i'd recommend it would depend somewhat on how the cat's his was - e.g., was she a "typical' overweight cat who was on a dry food diet, but otherwise has been feeling well and eating well? | Can you post the curves from 2.5 units bid? |
Boogie is an 11 year old MC Pomeranian agnosed with PD Cushings in February. We started him on Trilostane on March 18, 2013. His is 11.5 pounds and was started on compounded trilostane 20mg 1/2 tablet po q24hrs. The first monitoring ACTH stim was done on 3-29-13
Pre2.5ug/dl
Post 4.7ug/dl
My understanng is that this is reasonable post trilostane, but that it might go even lower. The owner was concerned about possible GI side effects associated with the trilostane at that time. We elected to switch to trilostane 20mg 1/4 tablet po q12hrs. The GI signs resolved.
The next ACTH stim was done on 5-9-13
Pre0.7ug/dl
Post 6.0ug/dl
The post value looks good to me, but I'm concerned the pre is too low. Should I consider decreasing the dose? Clinically, the owners have noticed a slight decrease in water intake and a decrease in his voracious appetitie. He is otherwise doing well at home.
I should note, both ACTH stims were started about 3hours after the morning trilostane.
Thanks!
☼ | Are you using cortrosyn or a gel for your stims? | Would this be why? |
Boogie is an 11 year old MC Pomeranian agnosed with PD Cushings in February. We started him on Trilostane on March 18, 2013. His is 11.5 pounds and was started on compounded trilostane 20mg 1/2 tablet po q24hrs. The first monitoring ACTH stim was done on 3-29-13
Pre2.5ug/dl
Post 4.7ug/dl
My understanng is that this is reasonable post trilostane, but that it might go even lower. The owner was concerned about possible GI side effects associated with the trilostane at that time. We elected to switch to trilostane 20mg 1/4 tablet po q12hrs. The GI signs resolved.
The next ACTH stim was done on 5-9-13
Pre0.7ug/dl
Post 6.0ug/dl
The post value looks good to me, but I'm concerned the pre is too low. Should I consider decreasing the dose? Clinically, the owners have noticed a slight decrease in water intake and a decrease in his voracious appetitie. He is otherwise doing well at home.
I should note, both ACTH stims were started about 3hours after the morning trilostane.
Thanks!
☼ | That's good...with food also hopefully? | What did it look like? |
I have a 16 yo female spayed overweightby approximately 3 pounds who is presenting with a recent onset of notable PU PD and is always hungry (but that portion is not new). She consumes canned DM as a diabetic preventative goal. She is on daily SAMe as her ALT in the past has been in the low 130s and an u/s guided aspirate of a year ago revealed mild hepatocellular vacuolation. Endogenous ACTH at that time was normal. Owners also report her pupils are concurrently always dilated since noticing the PU PD. Her urine in their opinion seems "heavy" when they scoop it out of the box. No vomiting is reported and her stools are normal. She is very aggressive at our hospital and heavy sedation is required for handling. Labwork perfomed reveals a normal CBC, chemistries are normal except for an ALT of 131, glucose of 160 and fsated cholesterol of 257. BUN=29.7 and Creatinine of 1.3. Her urinalysis was unremarkable except for a USG of 1.018-neg glucose, ketones, casts and cells. Her urine culture was negative The thyroid level is 1.4 and her fructosamine was WNL.. At this point I am uncertain as to the next steps to proceed with in face of symptoms that are concerning to the owner. Thoughts?
Thank you | What do you see on retinal examination? | As a schnauzer, they're very over-represented with familial hyperlipidemia....how are his fasting triglycerides looking? |