One more down...

Almost done with this month. Just got home a little while ago, have to be back at 4am. Had journal club today...my group presented...it went well. It was on renal failure which of course I think is great...but is not such an easy disease to understand. All in all though, it went good. Had some different cases today...one dog with hypoglycemia of 42!!! (normal is above 100!!). Was having continuous seizures - of course because of the low glucose, however the constant seizuring set up a seizure focus in the brain, causing the metabolic activity to rise...thus continuous complete generalized seizures (or status epilepticus to the rest of the world...but hey at AEC they call it complete generalized so that is what I will call it...for another 5 months!!). So he got loaded onto phenobarbital which ceased the seizures, however blood glucose was still in the 40's. Why? Well there is likely an insulin secreting tumor somewhere (less likely decreased production as bloodwork is normal; less likely increased demand). Owners are financially restricted so an ultrasound was performed which of course wasted $200 but didn't locate anything - rarely would - usually need CT or surgical explore. But they cannot and/or will not afford this. So, started on prednisone to try to increase glucose, maintained on phenobarb to try to keep seizures in check, and wanted to start another medication which decreases insulin secretion but the drug is $90/month and so owners declined. I sent him home this afternoon, probably things will not improve, medical management rarely works in these types of tumors and they are alos very aggressive...but I did my part...I laid options on the table and in the end made a treatment plan out of what I could. Have another cat who had a surgical exploratory because of anorexia and suspect foreign body...explore was negative (meaning no foreign body ostruction), but did get good full thickness biopsies of GI tract which is important in diagnosing GI disease...also biopsied liver and pancreas. But now cat is doing worse, still not eating, we are feeding it through the nasogastric tube...and owners are getting to the end of the financial limits...so plan to send home tomorrow prob with NGT in place and await biopsy results...what do I think it is? Maybe IBD, neoplasia (lymphoma), infectious. What else did I have? Another seizuring dog - first time 3yo Male intact (!!!) Rottweiler (yes he bites!!)...just monitored, since it was his first seizure did not phenoload - will if he has another...likely is epilepsy as all bloodwork was normal. I saw this big Portugese Sheepdog named Moose - he had a pyloric (region of stomach just before intestine) perforation, likely due to NSAID use (Deramaxx) , huge abdominal infection..had to place drains and flush abdomen daily- that was fixed by one of our ER docs...biopsies were sent in and came back as ulceration with intact duct material (possibly common bile duct)...BIG OOPS!!!! So, of course we worry about bile peritonitis..leakage...it was discussed on weather or not to go back in to surgery immediately..consesus was to monitor liver values and bilirubin as Moose was continuing to do well at that time...so he does well, is discharged on the 22nd...at that time T billi is high but we hope it will go down. He comes back today and I recheck liver values and I know they will be high as he is yellow on physical exam (jaundice or icteric as we call it)...and they are...se I recheck ultrasound...gall bladder is distended but scarey part is the free fluid... I collect some and run a T bili on it and it is 4.4 (higher than peripheral) and cytology reveals marked neutrophils, some degenerate but no bacteria....discuss with owners and decide to go back to surgery to see what can be done..if all looks normal then will take biopsies...because of the possibility of biliary tract involvement he went to surgery under the capable hands of our board certified surgeon...so I will find out results when I go back in a few hours!! What else..oh yeah two chronically boarding birds...parrots..who are doing fine but owner is a bit off her rocker and will not take them home...my management of them includes looking at them in the am and seeing that they are indeed still alive and sitting on their perches...and that is the extent of my bird doctoring skills...breathing -check, perching check, eating - check. Well, I am getting tired and it is time to transfer my white coats into the dryer and hit the sac. Webster is currently sitting on my lap and Patch is beside me...I swear they are like little burdoks...they stick to me...except that they are soft and the type of burr that you hope sticks with you through all the wash cycles of your life!!!