History : Last 48 hours has been lethargic, not eating, maybe one single vomit. Has lost weight over past months without Os trying - but unsure if this is pathological weight loss or not. Lameness on leg hasn't really changed it seems - unlikely the lethargy etc is related to that.
Examination: Cranial abdomen a bit tender on palpation. At one stage I thought I could feel a soft tisssue mass there, but at others I couldn't get it. This was in the area he seemed a bit tender. Not so tender and NAD in mid-caudal abdomen. Temp 39.4. Hydration - just notably off, maybe 3-4% dehydrated. CRT OK, pulse femoral OK, chest auscultates clear. Breath a bit smelly - teeth OK, maybe some areas ulceration in mouth but seem relatively minor.
Assessment: Unsure of relevance of palpation findings - hopefully irrelevant. In older dog with suspect weight loss in conjunction with these signs I feel investigation warranted.
Laboratory Results: In house ALKP mild elevation - 644 (23-212) Otherwise MBA NAD HCT, MCHC and HGB all mildly low. HCT 36.0 (37-55) WBC Mild increase 17.3 (5.5-16.9) N'phil % 80.6 (mild Hi), M'cyte % 13.7 (mod Hi) Plt also mild high. E'lytes normal. Spec cPL in house negative.
Then after a night on IV fluids this
Examination: After a night on IV fluids no improvement in demeanour noted. Temp down a little, pulse more prominent but notably CRT prologed - 2-3 secs now. R sided heart murmur noted - L side OK but this was not noted on R heart auscultation yesterday.
History : On speaking to O about Hx again today a few more potentially relevant facts were ascertained. Was walking OK for a while since last seen 8/12, but gradually became less and less interested in /able to walk. More lethargic in the heat. For a while before he stopped walking, he would only come part way on the walk. No panting, coughing, collapse notad on these occasions. Only past few days has appetite been reduced. O thinks he feels hot. Eyes have also been a bit gunky past few days where this has never been an issue before. Really O has noted more a mental loss of capacity - not protecting his patch, not interactive with visitors (humans or dogs) etc.
Assessment: Makes me feel like heart function must be called into question. While it seems unlikely heart is responsible for all these changes, it seems hard to ignore in a dog whose CRT and condition worsens on IV fluids.
Then began heart medication as don't have access to chest ultrasonography to assess heart function - this is from today.
Examination: This morning full exam - T 39.2, pulse less forceful, still wiry, CRT 1.5-2 secs. Hr 100-110=PR. Maybe slight increase sounds in lung fields today. Abdo palpation much as always - perhaps a touch less uncomfortable when palpated cranial abdomen. No V+, D+ etc - urinating well.
Laboratory Results: Blood pressure measurement - approx 95S - 45M - 30D on recording today - may have dropped a bit to low - will reduce frudix dose and consider begin on prilium if I feel response continues to this course of action.
Acupuncture performed today for the first time. Before treatment wiry pulse, a bit thin, neither deep nor superficial it seemed. Tongue purple centred, more red around edges.
Points that were functional - BL40 sedated -> reduced wiriness. BL 20 tonified smoothed the wiriness and filled it out a little.
Notably points that seemed to be ineffective GB 34, BL23, LIV13.
All in all I think I've been stumped a bit from a TCM perspective by the fact that this dog looks so deficient - lean and weak - but yet heat signs abound. I was initially thinking YGJ -with what I assumed was Yin deficiency, mild anemia etc etc.
It doesn't seem from these points that the empty heat I had kind of presumed was going on is actually there. In fact it seems heat with SP deficiency suggesting dampness and phlegm? What of the reducing BL40 being effective? Does this suggest a Yang Ming pathogen or similar? My current thought was to begin SMS (maybe with Dang Gui added with wiriness/stasis being such a feature?). Yin tonification (IV fluids) certainly tended to make him worse, and heart meds and cooling abcs (although no SP signs seen yet!) seem to have improved him somewhat. I have recently been assuming the tenderness in cranial abdomen (as can no longer feel any soft tissue mass I think is abnormal) is hypochodrial pain of some sort. Relevance?
I'm not sure if all this is coherant - there is too much going on in my head with this one currently. From Western diagnostic perspective I'm still thinking possibilities are autoimmune disease, neoplasia, endocarditis.
If you can make some sense of the patterns etc described, any help would be very appreciated! This has been a real brain drain for me this one!
Happy New Year - we'll beat you to it as always!
Mike