Hospice Consultation Summary

Pet Name: “Tiffany” Caro, 18 year old spayed female Persian cat.

Appointment Date: Friday, April 12, 2013

Regular Veterinarian (rDVM): Pebble Creek Animal & Bird Hospital

History: Her regular veterinarian previously diagnosed Tiffany with renal insufficiency, approximately March 2012. Lap of Love provided Tiffany’s first hospice consult on April 23, 2012. Owners have been maintaining Tiffany well on occasional SQ fluids, 1/8 tsp Miralax in water, and PO lactulose (1 mL, 10g/15mL). A few months ago she experienced constipation and needed transport to her rDVM for treatment with PO medications, no manual bowel evacuation was needed.

Owner’s Main Concerns: Quality of life, constipation, intermittent vomiting, addressing pain, not eating, difficult to pill

Current Medications / Treatment: 1/8 tsp. Miralax in water, PO lactulose 1 mL (10g/15mL)

Exam Findings: Tiffany was alert and responsive. She was not as bright-eyed as our previous hospice consult and was slightly ataxic (a new development). She was seen twice standing over the water fall bowl her owners recently purchased. Tiffany also allowed me to pick her up from the below the bed and examine her without argument, something she does not always do; she has been known to bite and verbally disagree!

·  Cardiovascular – HR ~100 bpm, left side systolic murmur grade 3/6

·  Respiration – RR ~40, lung auscult normal

·  Other - MM pale pink, crt <3 seconds, BCS 3/9, temperature WNL, significant muscle wasting consistent with old age

·  Signs of Pain – no overt signs of pain such as panting, crying, moaning; just discomfort associated with normal late stage renal failure.

Doctor’s Observations: Tiffany is progressing normally for renal failure. I consider her to be in “late to end” stage of the disease and although it is impossible to tell you how long she will be with us, I would think weeks to months. This is a very difficult thing to gauge, however, and is my best educated guess. Tiffany does not appear to be in a great deal of pain but humans in renal failure report a general feeling of “malaise” that can border on severe discomfort. Vomiting, diarrhea, constipation, ataxia, anorexia (not eating), changes in drinking, and “spaciness” (dysphoria) are all signs we may continue to see. At some point, one or more of these signs will not be controlled by medications and quality of life may become a concern. We are here to help walk that path with you and assist in interpretation of Tiffany’s condition.

Recommendations:

  1. Continue all previously prescribed medications.
  2. If upset stomach is suspected: Famotidine (OTC Pepcid AC) 10mg, give 2.5 mg by mouth every 12 hours. Most Pepcid AC comes in 20mg, so give 1/4 tablet twice a day.
  3. SQ fluids about once a week if possible. Determine the frequency based on the clinical signs. In other words, if Tiffany seems to perk up but then seems to act lethargic a day or two after this, you know it’s time to give her fluids. I would only administer the amount that she will comfortably sit for. She did great with 100 mLs today but 50-75 mLs might be best moving forward. Stick to whatever she’s comfortable with. Do not give more than about 100mLs, but I do not think she’s going to sit still to receive this much. You may also run the line through a bowl of hot water to warm the fluids while you are administering them.
  4. Kidney values and other blood parameters may continue to be monitored at your regular veterinarian’s office if you wish.
  5. Continue feeding the prescription diet if she will eat it! Otherwise, it is still best for her to eat something rather than nothing at all. Food will help keep her energy up.
  6. Nausea – occasional vomiting every 3-4 days may not be controlled by medication, though mirtazapine may help. If it does not, we can add other anti-emetics – please let me know how we can address this if it does not improve. Hypersalivating may be a sign of nausea so keep a look out for this.
  7. Encourage water consumption with fresh water in multiple locations. Adding ice cubes sometimes entices them to drink more. Water fountains can also encourage fluid intake simply because it’s entertaining so if she enjoys the one you bought, you may consider adding another one in a different part of the house.

Medications:

1.  SQ fluids 1-2 times a week, as long as Tiffany is not too stressed by the process (50-75 mL)

2.  Mirtazapine – appetitive stimulant, give as directed

3.  Lactulose – continue with dosage from rDVM

4.  Miralax – continue to add to all water unless bowel intolerance is seen

5.  Buprenorphine – pain medication, use as needed. Can also help if slightly constipated to relax Tiffany. Give as directed

6.  CoQ10 – 30 mg every other day by mouth has helped for some.

Please do not hesitate to contact us if you need anything at all!

Sincerely,

Dr. Dani McVety

T: 813 407-9441

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