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Robert Gracia Small Animal Clinical Nutrition

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Robert Gracia

This document describes two veterinary cases involving canine patients with nutritional needs. For case 1, the patient Bosco is a dog recovering from surgery to repair a fractured femur. Key nutritional factors for Bosco include high protein, fat, and calories given his recovery needs. The veterinarian would monitor Bosco's weight, appetite, and other parameters to ensure an adequate recovery feeding plan. For case 2, the patient Heidi has chronic active hepatitis. The veterinarian's initial treatment plan includes medications and a diet tailored to her condition. Parameters like weight and bloodwork would be monitored long-term to assess the treatment plan's adequacy.

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RobertGracia Small Animal Clinical Nutrition AVCID# 106395 August2, 2012 Case 1: Bosco Robinett Assessthe animal Bosco, a 3-year old,intactmale EnglishSpringer spaniel,wasrecentlystruckbya motor vehicle. He hadbeena healthydogpriorto the accident. Bosco sufferedafracturedrightfemur that wassuccessfullyrepairedbyone of the associate veterinariansinyourpractice. Post-operative recoverywas uneventful exceptforbacterial infectionof the suture line. A secondminorsurgical procedure wasnecessarytodraina small subcutaneousabscessandplace adrain. Boscois receiving parenteral antibioticsbasedonculture andsensitivitytestresults fromaspecimenobtainedfromthe infectedsurgical site. There isnoevidence of osteomyelitis. Your currentphysical examinationisunremarkable exceptforthe infectedsurgical siteandmildfever. Bosco currentlyweighs53poundswithan ideal BCS (3/5). Bosco is alertbutis confinedtoakennel in your hospital. He isallowedtogointoa small run fora few minutesseveral timeseachdaytoeliminate. You anticipate thathe will be hospitalizedforatleastanotherweekoruntil the infection iscompletely undercontrol. Assessthe foodandfeedingmethod Priortothe accident,Boscowasfeda grocery branddry dog food (AttaBoy). Table foodand rawhide chewswere offeredfrequently. Inthe hospital,Boscohasnotbeen offeredmuchfood because of the multiple surgical procedures. Hisappetite todayappeared questionable andyouare not sure if he is eatingenoughfoodtomeethisdailyenergyrequirements. You note inthe medical recordthathisappetite hasbeenpoorwhenhe wasboardedinyourfacilityin the past. Atta BoyDog Food Ingredients:Cookedyellow corn,meatandbone meal,cookedwheat,wheatbran, corn glutenmeal,animal fat(preservedwithmixedtocopherols),brewersrice,digestof poultryby- productmeal,poultry by-productmeal,canolaoil,fishmeal,tomatomeal,mineralsandvitamins. Guaranteedanalysis:Crude protein=not lessthan23%; crude fat = not lessthan9%; crude fiber=not more than 4%; moisture = notmore than 10%; calcium= not lessthan1% 320 kcal ME/cup Nutrition statement:Animal feedingtestsubstantiatethatAttaBoy Dog Foodprovidescompleteandbalanced nutritionforall life stages. GuidingQuestions1.Whatare the keynutritional factorstoconsiderinthispost-surgical patientwith secondarybacterial infection?2.Calculate Boscoscurrent,estimatedenergyneeds(i.e.illnessenergy requirement). Please show all work. How are yougoingto getthese caloriesintoBosco(i.e.how will youget himto consume all of the calories)?3.Basedon the current information,whatfood,food dosage,andfeedingmethodwouldyourecommendforBosco? How doesthisfoodcompare to the key nutritional factorsyoulistedinnumber1? What wouldyoudoif he refusestoeat?4. What parameters will youmonitortodetermine isyouare feedingplanisadequate,insufficient,orexcessive? How frequentlywillyoumonitorthese inthispatientandforhow long? What are your long-termnutrition- relatedplans(next2-3months) forBosco(i.e.plansforwhenhe goeshome)? Please be specificand thorough.
Case 1: Bosco Robinett 1. What are the keynutritional factorstoconsiderinthispost-surgical patientwithsecondarybacterial infection?The keynutritional factorswouldbe Highdigestibleproteins,Highdigestiblefats,low to moderate digestiblecarbohydrates,lowfiber,increasedpotassium,highlypalatable,prebiotics, probiotics,verysoftconsistencyforfeedingease throughtube if necessary. 2. Calculate Boscoscurrent,estimatedenergyneeds(i.e.illnessenergyrequirement). Pleaseshowall work. How are yougoingto get these caloriesintoBosco(i.e.how will yougethimtoconsume all of the calories)?53 lbs/2.2 lbs/kg=24.1 kg , 1.0 x RER = 1.0 x [70(24.1 kg).75]=761 kcal per dayinitially increasingthe multiplyingfactordependingonif weightlosshasoccurred,and/orhealthimprovement continues.Iwouldfirstbeginby measuringthe propercaloricamountof foodnecessaryforthe entire day andbreak thatamount upover4 - 6 feedings.Iwouldmeasure the total amountof foodfedfor each meal before andaftertofirstsee if Bosco isconsumingthe correctamount.If notinterestedin eatingI wouldtryto entice himintoeatingbyheatingthe food,handfeeding,ortryingto provide an appetite stimulantsuchasdiazepam,etc.If that doesnotworkthenI wouldplace a feedingtube in Bosco,such as a E tube or G tube to ensure the correctamountof caloriesisbeingconsumed. 3. Based onthe currentinformation,whatfood,fooddosage,andfeedingmethodwouldyou recommendforBosco? How doesthisfoodcompare to the keynutritional factorsyoulistedinnumber 1? What wouldyoudoif he refusestoeat?I wouldtryto feedBoscoa recoveryformulasuchas Hills Science DietA/D.Iwouldfeed4村 cans per day,whichisequal to 763 kcal ,Iwouldadjustamount accordinglyif weightlosshasoccurred,andas Bosco is becominghealthier. Iwouldbreakupthe feedingsinto6feedings.The first5feedingswouldbe 他of a can and the 6th feedingwouldbe 遜of a can. The latteris basedonlittle tono weightlossaswell asnohistoryof anorexiacausinganyGI compromise.If there hasbeenanorexiathenIwouldadhere tothe followingschedule: 1/3 of the daily caloricintake forday 1, 2/3 of the dailycaloricintake forday2, and the full dailycaloricintake forday3 and beyond.Thisfoodcontainsthe keynutritional factorsasI listedabove,exceptthatitdoesnot provide probioticsandprebioticstohelpreplenishthe normal gutflorainthe patientthatiscurrentlyon antibiotics.If BoscorefusestoeatthenIwouldmostlikelyplace afeedingtube suchasan E or G tube until Boscois consistentlyeatingonhisownforsome time. 4. What parameterswill youmonitortodetermineisyouare feedingplanisadequate,insufficient,or excessive? Howfrequentlywill youmonitorthese inthispatientandforhow long? What are your long- termnutrition-relatedplans(next2-3months) forBosco (i.e.plansforwhenhe goeshome)? Please be specificandthorough.Iwouldmonitorweighteverydayusingthe same scale andat the same time to determine weightgainorlossandpreserve consistency.Iwouldalsomonitordailydefecationsto ensure the dietisbeingtoleratedandthere are nosignsof diarrhea.Iwouldalsoperforma body conditionscore onBosco every2 to 3 days to see if I notice anysignificantdeviationsfromthe ideal.I wouldalsorunbloodglucose at leasttwice dailytoensure that Boscosglucose levelsdonotdropbelow normal levelsbetweenfeedingintervals.Iwouldmonitor all these levelsuntil Boscoisconsistentlyeatingonhisownorhas leftthe hospital.If Boscoisat home and still beingfedbytube Iwouldhave toadjustwhatmonitoringIcoulddo accordingto the ownerand availability.Once BoscoiseatingconsistentlyIwouldremove the tube if itwasnecessaryandstartto transitionhimovertohisnewdiet.Iwouldrecommendtryingtograduallydecrease the amountof table foodand rawhidesthatBoscowas receivinginthe pastbecause theyare a source of increasedcalories
and notnecessarilyof anysignificantnutritional benefit.If inthe pastBoscowas at an ideal body conditionscore,andwashealthywhile beingfedAttaBoyDogfood,thenI see noneedto change that food.I wouldfeedhimthe recommendedcaloricamountforan intactmale 53 lbs/2.2 lbs/kg=24.1 kg , 1.8 x RER = 1.8 x [70(24.1 kg).75]=1,371 kcal per day.Thisis equivalentto4 村 to 4 遜 cups of Atta Boy dog foodperday.I wouldbreakthe meal upintotwoseparate feedingsof 2 村 cups each.I wouldlike to see Boscoback in twoweekstocheckhisweight andperforma bodyconditionscore.Iwouldadjustdiet accordinglydependingonmyfindings.Once the infectionhassubsidedandBoscoisoff antibioticsI wouldlike tostarthimon a course of prebiotics/probiotics(fortiflor,bene bac) tohelprestore normal gut flora.Recheckradiographstoensure properfracture healing.Iwouldalsorecommendthatif Bosco isnot goingto be a stud,the ownersmayconsidercastrationat a latertime,since thismayhelpprevent roamingand decrease the riskof anothermotorvehicle encounter.(The latterisdependentonif the accidentoccurredoff the propertyetc.) If the ownersdoelecttohave Bosco castratedthenthe amount of foodbeingfedmustbe recalculatedforadog thatis no longerintactandalso depends onhiscurrent activitylevel. Case 2. Heidi Willis Assessthe PatientHeidi,a7-yearold,spayedfemale,Dobermanpinscher,ispresentedtoyourclinicfor herannual heartwormtest. She currentlyweighs60pounds. Heidi isan outdoordogwho is keptina fencedbackyard or chainlinkkennel withinsulateddoghouse. She liveswithhercaregiver,Ms.Willis, and 2 elderlycats. She iscurrenton all of her vaccinations. Yourphysical examinationrevealsalean and alertDobermanwitha BCSof 2/5. The medical recordindicatesthatshe weighed69poundsand had a BCS of 3/5 two yearsearlier. Blooddrawnfor the heartwormtestrevealsayellow tinge tothe plasma. Beingconcerned,youdraw more bloodand submititfora CBC andserumbiochemistryprofile. The dogsurinarybladderisbarely palpable butyoumanage to obtain5 cc of urine viacystocentesisforaUA. On a secondand more careful look,younotice thathermucousmembranesappearicteric. The onlyabnormalitynotedonthe CBC resultsisa commentaboutoccasional targetcellsbeingseenonthe microscopicexaminationof the bloodsmear. Abnormalitiesonthe serumbiochemical profile include albumin=1.9 g/dl (normal 2.5-3.8 g/dl);BUN = 8 mg/dl (normal 9-27 mg/dl);ALT= 301 IU (normal 21-67 IU); SAP= 362 IU (normal 14-72 IU); and total bilirubin=2.5 mg/dl (normal < 0.3 mg/dl). The urinalysisrevealsa3+ bilirubinuriawitha specificgravityof 1.030 and a urine pH of 7.0. Additional workup:surveyabdominal radiography(small liver) andliverbiopsy(hepaticdegenerationandnecrosiswithamixedinflammatoryresponse). of copper/gof tissue). Yoususpectchronicactive hepatitis. Assessthe FoodandFeedingMethodHeidi hasbeenfree choice feddry,High-Prodogfood. However, Ms. WillisindicatedthatHeidisappetite wasabitoffbecause she wasnot refillingHeidisfoodbowl as often. High-ProDogFood Ingredientlist:Cookedyellow corn,meatandbone meal,cookedwheat,wheatbran, corn glutenmeal,animal fat(preservedwithmixedtocopherols),brewersrice,digestof poultry
byproductmeal,poultryby-productmeal,canolaoil,fishmeal,tomatomeal,mineralsandvitamins. Guaranteedanalysis:27%protein;10% fat;4% fiber;12% moisture Nutritionstatement:Hi-Prois formulatedtoprovide complete andbalancednutritionformaintenance. GuidingQuestions1.Giventhisinformation,whatisyourinitial treatmentplan? Please be concise and thorough.2. What are the keynutritional factors(KNF) andtheirappropriatelevelstoconsiderforthis patient?3. What food,fooddosage andfeedingmethodwouldyourrecommendforHeidi (show all work)? How doesthe foodcompare withthe keynutritional factors(i.e.compare eachfactor) youlisted inquestion2? Whenand howwill youintroduce yourchosenfood?4.What are yourlong-termplans for Heidi? Whatparameterswill youmonitortodetermine if yourtreatmentisadequate,insufficient,or excessive? Howfrequentlywill youmonitorthese inthispatientandforhow long? Case 2: Heidi Willis 1. Giventhisinformation,whatisyourinitial treatmentplan? Please be concise andthorough.If any signsof dehydrationIwouldbeginwithfluidtherapytoreplace losesandtocorrect any electrolyte imbalances.IwouldstartHeidi ona course of prednisolone(glucocorticoids) andantibiotics(depending on culture or can use ampicillin,metronidazole,etc.) for1 2 months.Alsostarton hepatoprotectants (ursodiol),andpossiblysupplementwithVitaminCandZinc to decrease copperlevels.Bvitaminsand digestive enzymesupplementationcanalsobe given.Provide supportforanyotherclinical signsthat developsuchasvomiting,ascites,etc.Provide anew dietwithhighqualityrestrictedproteinandcertain minerals.Recheckin2weekstodetermine weightgain,anddiettolerance.Recheckbloodlevelswhile on steroids.Followupradiographsand/orultrasoundtodetermineascitesorprogressionof cirrhosis. Additional liverbiopsyasneededdue tolongtermglucocorticoidtreatment. 2. What are the keynutritional factors(KNF) andtheirappropriate levelstoconsiderforthispatient? The keynutritional factorsforthispatientare highqualityandhighlydigestible moderate amountsof protein,normal amountof highlydigestible fat,normal amountof highlydigestible carbohydrates, higherlevelsof fermentablefiber,normal toslightlyhigherlevelsof taurine,iron,zinc,potassium,L- Carnitine,andvitamins,decreasedlevelsof sodiumchloride,andcopper. 3. What food,fooddosage and feedingmethodwouldyourecommendforHeidi (show all work)? How doesthe foodcompare withthe keynutritional factors(i.e.compare eachfactor) youlistedinquestion 2? Whenand howwill youintroduce yourchosenfood?IwouldfeedHeidi HillsScience DietL/DCanine HepaticHealth.IwouldfeedHeidi forweight gaintobringherback to an ideal body conditionscore,butstartingoutat a lowermultipliersince she mighthave beenanorexic.If there has beenanorexiathenIwouldadhere tothe followingschedule: 1/3of the dailycaloricintake forday1, 2/3 of the dailycaloricintake forday2, and the full dailycaloricintake forday3 and beyond.69 lbs/2.2 lbs/kg=31.4 kg , 1.2 x RER = 1.2 x [70(31.4 kg).75]= 1,113 kcal per day.I wouldfeed2他 cupsto 3 cups perday, 1 遜 cupstwice dailyequal to1,197 kcal per day.The keynutritional factorsmatchup well concerningprotein,carbohydrates,fat,fiber,L- Carnitine,copper,iron,zinc,potassium, andsodium, I couldnot findinformationaboutthe varioustypesof vitamins,andtaurine andthere levels includedin the diet.I wouldintroduce the foodtoHeidi athome ratherthan the clinicsothat she wouldnotbe adverse toit.I wouldslowlyswitchherovertothe new foodovera weeklongperiodasfollows:day1=
90% old,10% new;day 2= 75% old,25% new;day3= 60% old,40% new;day 4= 50% old,50% new;day 5= 40% old,60% new;day 6= 25% old,75% new;day7= 10% old,90% new;day8= 100% new diet. 4. What are your long-termplansforHeidi? Whatparameterswillyoumonitortodetermineif your treatmentisadequate,insufficient,orexcessive? How frequentlywillyoumonitorthese inthispatient and forhow long?I wouldstartHeidi ona course of prednisolone (glucocorticoids) andantibiotics (dependingonculture orcan use ampicillin,metronidazole,etc.) for1 2 months.Alsostarton hepatoprotectants(ursodiol),andpossiblysupplementwithVitaminC,E and Zincto decrease copper levels.Bvitaminsanddigestiveenzyme supplementationcanalsobe given.Provide supportforany otherclinical signsthatdevelopsuchasvomiting,ascites,etc.Recheckin2weekstodetermine weight gain,and diettolerance.Reweighandassessdiet,recheckagainevery2weeksuntil weightlevel is appropriate thenadjustcaloricintake formaintenance.Recheckbloodlevels(Albumin,AST,ALP,total Bilirubin,BUN,CBC,WBC,copper,sodium, potassium,etc.) while onsteroidsforlongterm.Followup radiographs and/orultrasoundina couple of monthstodetermine ascitesorprogressionof cirrhosis. Additional liverbiopsyasneededdue tolongtermglucocorticoidtreatment.Iwouldmonitorweight, BCS, bloodlevels,andradiographs.Once Heidiisata good weightshe canbe monitoredforweight stabilityevery4to6 months,andbloodlevelsatleasttwice yearly,andradiographs/ultrasoundatleast yearly.

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Robert Gracia Small Animal Clinical Nutrition

  • 1. RobertGracia Small Animal Clinical Nutrition AVCID# 106395 August2, 2012 Case 1: Bosco Robinett Assessthe animal Bosco, a 3-year old,intactmale EnglishSpringer spaniel,wasrecentlystruckbya motor vehicle. He hadbeena healthydogpriorto the accident. Bosco sufferedafracturedrightfemur that wassuccessfullyrepairedbyone of the associate veterinariansinyourpractice. Post-operative recoverywas uneventful exceptforbacterial infectionof the suture line. A secondminorsurgical procedure wasnecessarytodraina small subcutaneousabscessandplace adrain. Boscois receiving parenteral antibioticsbasedonculture andsensitivitytestresults fromaspecimenobtainedfromthe infectedsurgical site. There isnoevidence of osteomyelitis. Your currentphysical examinationisunremarkable exceptforthe infectedsurgical siteandmildfever. Bosco currentlyweighs53poundswithan ideal BCS (3/5). Bosco is alertbutis confinedtoakennel in your hospital. He isallowedtogointoa small run fora few minutesseveral timeseachdaytoeliminate. You anticipate thathe will be hospitalizedforatleastanotherweekoruntil the infection iscompletely undercontrol. Assessthe foodandfeedingmethod Priortothe accident,Boscowasfeda grocery branddry dog food (AttaBoy). Table foodand rawhide chewswere offeredfrequently. Inthe hospital,Boscohasnotbeen offeredmuchfood because of the multiple surgical procedures. Hisappetite todayappeared questionable andyouare not sure if he is eatingenoughfoodtomeethisdailyenergyrequirements. You note inthe medical recordthathisappetite hasbeenpoorwhenhe wasboardedinyourfacilityin the past. Atta BoyDog Food Ingredients:Cookedyellow corn,meatandbone meal,cookedwheat,wheatbran, corn glutenmeal,animal fat(preservedwithmixedtocopherols),brewersrice,digestof poultryby- productmeal,poultry by-productmeal,canolaoil,fishmeal,tomatomeal,mineralsandvitamins. Guaranteedanalysis:Crude protein=not lessthan23%; crude fat = not lessthan9%; crude fiber=not more than 4%; moisture = notmore than 10%; calcium= not lessthan1% 320 kcal ME/cup Nutrition statement:Animal feedingtestsubstantiatethatAttaBoy Dog Foodprovidescompleteandbalanced nutritionforall life stages. GuidingQuestions1.Whatare the keynutritional factorstoconsiderinthispost-surgical patientwith secondarybacterial infection?2.Calculate Boscoscurrent,estimatedenergyneeds(i.e.illnessenergy requirement). Please show all work. How are yougoingto getthese caloriesintoBosco(i.e.how will youget himto consume all of the calories)?3.Basedon the current information,whatfood,food dosage,andfeedingmethodwouldyourecommendforBosco? How doesthisfoodcompare to the key nutritional factorsyoulistedinnumber1? What wouldyoudoif he refusestoeat?4. What parameters will youmonitortodetermine isyouare feedingplanisadequate,insufficient,orexcessive? How frequentlywillyoumonitorthese inthispatientandforhow long? What are your long-termnutrition- relatedplans(next2-3months) forBosco(i.e.plansforwhenhe goeshome)? Please be specificand thorough.
  • 2. Case 1: Bosco Robinett 1. What are the keynutritional factorstoconsiderinthispost-surgical patientwithsecondarybacterial infection?The keynutritional factorswouldbe Highdigestibleproteins,Highdigestiblefats,low to moderate digestiblecarbohydrates,lowfiber,increasedpotassium,highlypalatable,prebiotics, probiotics,verysoftconsistencyforfeedingease throughtube if necessary. 2. Calculate Boscoscurrent,estimatedenergyneeds(i.e.illnessenergyrequirement). Pleaseshowall work. How are yougoingto get these caloriesintoBosco(i.e.how will yougethimtoconsume all of the calories)?53 lbs/2.2 lbs/kg=24.1 kg , 1.0 x RER = 1.0 x [70(24.1 kg).75]=761 kcal per dayinitially increasingthe multiplyingfactordependingonif weightlosshasoccurred,and/orhealthimprovement continues.Iwouldfirstbeginby measuringthe propercaloricamountof foodnecessaryforthe entire day andbreak thatamount upover4 - 6 feedings.Iwouldmeasure the total amountof foodfedfor each meal before andaftertofirstsee if Bosco isconsumingthe correctamount.If notinterestedin eatingI wouldtryto entice himintoeatingbyheatingthe food,handfeeding,ortryingto provide an appetite stimulantsuchasdiazepam,etc.If that doesnotworkthenI wouldplace a feedingtube in Bosco,such as a E tube or G tube to ensure the correctamountof caloriesisbeingconsumed. 3. Based onthe currentinformation,whatfood,fooddosage,andfeedingmethodwouldyou recommendforBosco? How doesthisfoodcompare to the keynutritional factorsyoulistedinnumber 1? What wouldyoudoif he refusestoeat?I wouldtryto feedBoscoa recoveryformulasuchas Hills Science DietA/D.Iwouldfeed4村 cans per day,whichisequal to 763 kcal ,Iwouldadjustamount accordinglyif weightlosshasoccurred,andas Bosco is becominghealthier. Iwouldbreakupthe feedingsinto6feedings.The first5feedingswouldbe 他of a can and the 6th feedingwouldbe 遜of a can. The latteris basedonlittle tono weightlossaswell asnohistoryof anorexiacausinganyGI compromise.If there hasbeenanorexiathenIwouldadhere tothe followingschedule: 1/3 of the daily caloricintake forday 1, 2/3 of the dailycaloricintake forday2, and the full dailycaloricintake forday3 and beyond.Thisfoodcontainsthe keynutritional factorsasI listedabove,exceptthatitdoesnot provide probioticsandprebioticstohelpreplenishthe normal gutflorainthe patientthatiscurrentlyon antibiotics.If BoscorefusestoeatthenIwouldmostlikelyplace afeedingtube suchasan E or G tube until Boscois consistentlyeatingonhisownforsome time. 4. What parameterswill youmonitortodetermineisyouare feedingplanisadequate,insufficient,or excessive? Howfrequentlywill youmonitorthese inthispatientandforhow long? What are your long- termnutrition-relatedplans(next2-3months) forBosco (i.e.plansforwhenhe goeshome)? Please be specificandthorough.Iwouldmonitorweighteverydayusingthe same scale andat the same time to determine weightgainorlossandpreserve consistency.Iwouldalsomonitordailydefecationsto ensure the dietisbeingtoleratedandthere are nosignsof diarrhea.Iwouldalsoperforma body conditionscore onBosco every2 to 3 days to see if I notice anysignificantdeviationsfromthe ideal.I wouldalsorunbloodglucose at leasttwice dailytoensure that Boscosglucose levelsdonotdropbelow normal levelsbetweenfeedingintervals.Iwouldmonitor all these levelsuntil Boscoisconsistentlyeatingonhisownorhas leftthe hospital.If Boscoisat home and still beingfedbytube Iwouldhave toadjustwhatmonitoringIcoulddo accordingto the ownerand availability.Once BoscoiseatingconsistentlyIwouldremove the tube if itwasnecessaryandstartto transitionhimovertohisnewdiet.Iwouldrecommendtryingtograduallydecrease the amountof table foodand rawhidesthatBoscowas receivinginthe pastbecause theyare a source of increasedcalories
  • 3. and notnecessarilyof anysignificantnutritional benefit.If inthe pastBoscowas at an ideal body conditionscore,andwashealthywhile beingfedAttaBoyDogfood,thenI see noneedto change that food.I wouldfeedhimthe recommendedcaloricamountforan intactmale 53 lbs/2.2 lbs/kg=24.1 kg , 1.8 x RER = 1.8 x [70(24.1 kg).75]=1,371 kcal per day.Thisis equivalentto4 村 to 4 遜 cups of Atta Boy dog foodperday.I wouldbreakthe meal upintotwoseparate feedingsof 2 村 cups each.I wouldlike to see Boscoback in twoweekstocheckhisweight andperforma bodyconditionscore.Iwouldadjustdiet accordinglydependingonmyfindings.Once the infectionhassubsidedandBoscoisoff antibioticsI wouldlike tostarthimon a course of prebiotics/probiotics(fortiflor,bene bac) tohelprestore normal gut flora.Recheckradiographstoensure properfracture healing.Iwouldalsorecommendthatif Bosco isnot goingto be a stud,the ownersmayconsidercastrationat a latertime,since thismayhelpprevent roamingand decrease the riskof anothermotorvehicle encounter.(The latterisdependentonif the accidentoccurredoff the propertyetc.) If the ownersdoelecttohave Bosco castratedthenthe amount of foodbeingfedmustbe recalculatedforadog thatis no longerintactandalso depends onhiscurrent activitylevel. Case 2. Heidi Willis Assessthe PatientHeidi,a7-yearold,spayedfemale,Dobermanpinscher,ispresentedtoyourclinicfor herannual heartwormtest. She currentlyweighs60pounds. Heidi isan outdoordogwho is keptina fencedbackyard or chainlinkkennel withinsulateddoghouse. She liveswithhercaregiver,Ms.Willis, and 2 elderlycats. She iscurrenton all of her vaccinations. Yourphysical examinationrevealsalean and alertDobermanwitha BCSof 2/5. The medical recordindicatesthatshe weighed69poundsand had a BCS of 3/5 two yearsearlier. Blooddrawnfor the heartwormtestrevealsayellow tinge tothe plasma. Beingconcerned,youdraw more bloodand submititfora CBC andserumbiochemistryprofile. The dogsurinarybladderisbarely palpable butyoumanage to obtain5 cc of urine viacystocentesisforaUA. On a secondand more careful look,younotice thathermucousmembranesappearicteric. The onlyabnormalitynotedonthe CBC resultsisa commentaboutoccasional targetcellsbeingseenonthe microscopicexaminationof the bloodsmear. Abnormalitiesonthe serumbiochemical profile include albumin=1.9 g/dl (normal 2.5-3.8 g/dl);BUN = 8 mg/dl (normal 9-27 mg/dl);ALT= 301 IU (normal 21-67 IU); SAP= 362 IU (normal 14-72 IU); and total bilirubin=2.5 mg/dl (normal < 0.3 mg/dl). The urinalysisrevealsa3+ bilirubinuriawitha specificgravityof 1.030 and a urine pH of 7.0. Additional workup:surveyabdominal radiography(small liver) andliverbiopsy(hepaticdegenerationandnecrosiswithamixedinflammatoryresponse). of copper/gof tissue). Yoususpectchronicactive hepatitis. Assessthe FoodandFeedingMethodHeidi hasbeenfree choice feddry,High-Prodogfood. However, Ms. WillisindicatedthatHeidisappetite wasabitoffbecause she wasnot refillingHeidisfoodbowl as often. High-ProDogFood Ingredientlist:Cookedyellow corn,meatandbone meal,cookedwheat,wheatbran, corn glutenmeal,animal fat(preservedwithmixedtocopherols),brewersrice,digestof poultry
  • 4. byproductmeal,poultryby-productmeal,canolaoil,fishmeal,tomatomeal,mineralsandvitamins. Guaranteedanalysis:27%protein;10% fat;4% fiber;12% moisture Nutritionstatement:Hi-Prois formulatedtoprovide complete andbalancednutritionformaintenance. GuidingQuestions1.Giventhisinformation,whatisyourinitial treatmentplan? Please be concise and thorough.2. What are the keynutritional factors(KNF) andtheirappropriatelevelstoconsiderforthis patient?3. What food,fooddosage andfeedingmethodwouldyourrecommendforHeidi (show all work)? How doesthe foodcompare withthe keynutritional factors(i.e.compare eachfactor) youlisted inquestion2? Whenand howwill youintroduce yourchosenfood?4.What are yourlong-termplans for Heidi? Whatparameterswill youmonitortodetermine if yourtreatmentisadequate,insufficient,or excessive? Howfrequentlywill youmonitorthese inthispatientandforhow long? Case 2: Heidi Willis 1. Giventhisinformation,whatisyourinitial treatmentplan? Please be concise andthorough.If any signsof dehydrationIwouldbeginwithfluidtherapytoreplace losesandtocorrect any electrolyte imbalances.IwouldstartHeidi ona course of prednisolone(glucocorticoids) andantibiotics(depending on culture or can use ampicillin,metronidazole,etc.) for1 2 months.Alsostarton hepatoprotectants (ursodiol),andpossiblysupplementwithVitaminCandZinc to decrease copperlevels.Bvitaminsand digestive enzymesupplementationcanalsobe given.Provide supportforanyotherclinical signsthat developsuchasvomiting,ascites,etc.Provide anew dietwithhighqualityrestrictedproteinandcertain minerals.Recheckin2weekstodetermine weightgain,anddiettolerance.Recheckbloodlevelswhile on steroids.Followupradiographsand/orultrasoundtodetermineascitesorprogressionof cirrhosis. Additional liverbiopsyasneededdue tolongtermglucocorticoidtreatment. 2. What are the keynutritional factors(KNF) andtheirappropriate levelstoconsiderforthispatient? The keynutritional factorsforthispatientare highqualityandhighlydigestible moderate amountsof protein,normal amountof highlydigestible fat,normal amountof highlydigestible carbohydrates, higherlevelsof fermentablefiber,normal toslightlyhigherlevelsof taurine,iron,zinc,potassium,L- Carnitine,andvitamins,decreasedlevelsof sodiumchloride,andcopper. 3. What food,fooddosage and feedingmethodwouldyourecommendforHeidi (show all work)? How doesthe foodcompare withthe keynutritional factors(i.e.compare eachfactor) youlistedinquestion 2? Whenand howwill youintroduce yourchosenfood?IwouldfeedHeidi HillsScience DietL/DCanine HepaticHealth.IwouldfeedHeidi forweight gaintobringherback to an ideal body conditionscore,butstartingoutat a lowermultipliersince she mighthave beenanorexic.If there has beenanorexiathenIwouldadhere tothe followingschedule: 1/3of the dailycaloricintake forday1, 2/3 of the dailycaloricintake forday2, and the full dailycaloricintake forday3 and beyond.69 lbs/2.2 lbs/kg=31.4 kg , 1.2 x RER = 1.2 x [70(31.4 kg).75]= 1,113 kcal per day.I wouldfeed2他 cupsto 3 cups perday, 1 遜 cupstwice dailyequal to1,197 kcal per day.The keynutritional factorsmatchup well concerningprotein,carbohydrates,fat,fiber,L- Carnitine,copper,iron,zinc,potassium, andsodium, I couldnot findinformationaboutthe varioustypesof vitamins,andtaurine andthere levels includedin the diet.I wouldintroduce the foodtoHeidi athome ratherthan the clinicsothat she wouldnotbe adverse toit.I wouldslowlyswitchherovertothe new foodovera weeklongperiodasfollows:day1=
  • 5. 90% old,10% new;day 2= 75% old,25% new;day3= 60% old,40% new;day 4= 50% old,50% new;day 5= 40% old,60% new;day 6= 25% old,75% new;day7= 10% old,90% new;day8= 100% new diet. 4. What are your long-termplansforHeidi? Whatparameterswillyoumonitortodetermineif your treatmentisadequate,insufficient,orexcessive? How frequentlywillyoumonitorthese inthispatient and forhow long?I wouldstartHeidi ona course of prednisolone (glucocorticoids) andantibiotics (dependingonculture orcan use ampicillin,metronidazole,etc.) for1 2 months.Alsostarton hepatoprotectants(ursodiol),andpossiblysupplementwithVitaminC,E and Zincto decrease copper levels.Bvitaminsanddigestiveenzyme supplementationcanalsobe given.Provide supportforany otherclinical signsthatdevelopsuchasvomiting,ascites,etc.Recheckin2weekstodetermine weight gain,and diettolerance.Reweighandassessdiet,recheckagainevery2weeksuntil weightlevel is appropriate thenadjustcaloricintake formaintenance.Recheckbloodlevels(Albumin,AST,ALP,total Bilirubin,BUN,CBC,WBC,copper,sodium, potassium,etc.) while onsteroidsforlongterm.Followup radiographs and/orultrasoundina couple of monthstodetermine ascitesorprogressionof cirrhosis. Additional liverbiopsyasneededdue tolongtermglucocorticoidtreatment.Iwouldmonitorweight, BCS, bloodlevels,andradiographs.Once Heidiisata good weightshe canbe monitoredforweight stabilityevery4to6 months,andbloodlevelsatleasttwice yearly,andradiographs/ultrasoundatleast yearly.