Louie has a medical history of:
-Mitral valve disease
-Bilateral CCL repair and subsequent OA
-A 5cm liver mass, first noted on ultrasound in June 2018. It has not progressed on repeat ultrasounds (no cytology)
-Collapsing trachea
-Mild hearing loss
-periodontal disease
-Intermittent liver enzyme elevation (typically will be elevated in the fall
Louie is a wood personality and has historically been aggressive and will bite when asked to do something he does not want to do.
Over the last year Louie has had some interesting and progressive personality changes attributed to cognitive dysfunction. He initially developed a phobia of light and would tremble and be fearful of any flashing lights at night. Sometimes the only way he would sleep at night would be to keep the light on. This has progressed to agitation and pacing at night. It typically will start at 1:45 am and he will settle down on his own by 5:30. In that time he tries to knock things over and scratches at anything that will make a loud noise. The top of his head and neck seem warm while he is doing this, but never feels warm during the day. He also has a deep cough at night that seems like it may be the result of reflux as he will wretch at the end. The cough never occurs during the day. He is drinking more water than usual and will occasionally exhibit night time urinary incontinence. his appetite is normal.
Last week, he woke up in the morning and was shaking, lethargic, inappetant and febrile (103 F). By the time he got to the ER he was looking a little brighter and temp was normal. He was hospitalized overnight and lab work showed significant elevations in ALT, GGT, ALP and mild azotemia. After started clavamox and metronidazole and 24 hours on IVF he was doing much better. His appetite returned, his lab values improved by 60%.
His tongue is red with slight purple tint with no coating. His pulse is thin, toned and superficial
Prior to his hospitalization his tongue was more red, which isn’t typical for him so I already started him on Rehmannia 6 and he was on this for about 2 weeks prior to having to be hospitalized. Since returning home from the hospital I changed his herbs and he’s been on Xiao Yao San with maybe only slight improvement in the night pacing.
He eats cooked, kidney support, lamb based diet. He is currently taking the following supplements:
-melatonin 2.5 mg po before bed
-0.5 mg diazepam before bed
-1000 mg fish oil twice daily
-sam-e
-Thorne Hepagen formula once daily
-xiao Yao san 1/4 teaspoon twice daily
-vetmedin 1.25 mg twice daily
-finishing up clavamox and metronidazole
-Jing Tang Heart Qi Tonic (long term supplement)
-Jing Tang Shen Calmer (long term supplement)
I’m thinking he has liver qi stagnation and yin deficiency. The hospitalization last week had me thinking about Shao Yang Syndrome. Now I’m confused and exhausted from no keep and sure could use some help! Acupuncture is out of the question because he would try to bite!
Thank you!!!