Feb 2025 O returned saying the shivers are becoming more frequent again and appetite off and on fussy, sometimes she looks hunched. Ran general panel - CBC: Sl elevated RBC and HBG, CHEM: sl ^ BUN - but on high protein diet, ^TP and alb - inflammation - teeth, liver?, ^ALT and tbili - liver inflammation - poss PVH? Rec bile acids - moderate to severe elevations (>40) found. Given TDG codeine prn for pain and ordered abs U/S. IN the meantime, I added Ge Xia Zhu Yu Tang (for the analgesic effect because she seemed more irritable, restless, painful) and milk thistle as I suspected PVH/MVD. Confirmed microvascular dysplasia on U/S. Reran bile acids: both elevated again, even further than last BAs: pre 63.7, post: 89.7.
By April, O reported she is better on herbs, but appetite still waxes and wanes. Way more living and cuddly, way less aggressive, less reactive on leash. No real intense "violent" shivering lately, had only had to give codeine once. BMs mostly WNL, maybe a little softer, but well formed. At this point, I addied Xiao Yao San to better reduce inflammation and improve liver perfusion (and hopefully improve appetite, BM consistency, and EN).
She did well all Spring and summer for the most part, dental in June, but came back October 15th. Since Sept 10th eating better again, but prior to intermittently reduced appetite, rare shivers. O gave Ivermectin horse paste/liquid on Sept 10th and SID for a few weeks, and had been eating really well until recently again. However, licking wood now, licking more in general - at the floor, O's pants, occas carpet, but sporadic and doesn't spend a ton of time doing this. Last 3 days shivering intensely again, seemed uncomfortable, hunched back, eyes sunken. Started codeine again 2 nights ago, just at night, reduced violent shaking. Last 2 days appetite sl reduced, but generally had been more voracious on occasion too. Still on 1/8 tsp GXZYT BID, 1/8 tsp XYS BID, 1/16 tsp Halscion in am only (had dropped this down because she seemed to get really itchy all over when on BID), and milk thistle 0.35ml in pm. Still has itchy times, but doesn't seem to relate to Halscion. More reactive as well with other dogs this Fall. BMs always WNL.
On PE, her tongue is pink, sl dry (but excited and panting), sl swollen in appearance; pulses sl taut but toned. She is in excellent physical condition, BCS 4/9, BAR, lively, and sweet. The shivering again I think is Liver Qi Stagnation, the licking either Dampness or Stomach Yin deficiency. I decided to increase the Halscion back to BID and aim for 1/8 tsp BID. The O now thinks her itchiness was due to an environmental cause. Then I started to doubt myself with the sl swollen tongue and wonder if I should switch her from GXZYT to DGSYS or YGJ? I know the Fall (and morning) is when there is major seasonal changes in circulation, esp with the liver, causing elevated liver enzymes due to impaired portal circulation. YGJ makes sense for low grade itch, reactivity, pale tongue, abd pain, but she's not losing wt, V+, nor does she have a strong appetite. XYS makes sense to move stagnant Qi (shivers), but her stools are WNL, no overt Dampness that I can see though other than tongue? DGSYS for reduced appetite but may be too drying?? Now I'm all confused again!!!
I would love to take bloods again on this dog but it is a real struggle, she is so small and cries horribly. We had to sedate last time which I obviously prefer not to do.
HELP!
Corinne