C10030568 / invoice 10000

BIB Ina

HISTORY
Presenting for: Diabetes review 

Historical Conditions:
- Diabetes mellitus - diagnosed previously, has been diabetic since May 2024 
- Bilateral cataracts secondary to diabetes - assessed by ophthalmologist as poor surgical candidate due to high risk, no guarantee of good outcome
- Vision loss secondary to cataracts
- Previous glucose sensor monitoring in October showed averages of 16.4, 18.9, 20.9

Diet:
- Diabetic dry food plus frozen meat (chicken necks and protein blend)
- Minimal / low carbohydrates in diet
- Appetite described as really good, sometimes moderately increased

Drinking/Urination:
- Owner reports drinking and urination not particularly excessive
- Occasionally wakes owner at night to go outside, attributed to increased drinking but not considered excessive
- Multiple animals in household making individual monitoring difficult

Skin:
- Progressive hair loss noted on legs but not trunk and body also affected. Bilateral pattern, 
- Hair thinning and coat changes - alopecia

Current Meds:
- Toujeo insulin 18 units every 12 hours BID
- Azopt eye drops BID for cataracts
- Acular eye drops BID for cataracts
- Overdue for flea treatment and worming

EXAM
Wt: 29.7kg (decreased from 30.25kg in October - minimal weight loss)
Behavioural: Cooperative for examination
Eyes: Bilateral cataracts present, vision loss confirmed
Integumentary: Significant hair loss and thinning noted on legs and body with dull poor coat quality
Diagnostics: Urine test - negative for glucose, USG1.045 (concentrated urine)

ASSESSMENT
Diabetes mellitus - currently well controlled clinically based on stable weight, normal appetite and drinking patterns, though urine glucose negative suggesting possible overtreatment (hypoglycemia)
Hair loss and coat changes - DDx: hypothyroidism, hyperadrenocorticism (Cushing's disease), alopecia X, 

PLAN
Diagnostics:
- Repeat urine sample collection requested to confirm glucose levels - if continues negative, blood glucose curve using Freestyle Libre Sensor and insulin dose reduction may be required
- Thyroid panel testing recommended (due April for routine bloods)
- ACTH stimulation test discussed for Cushing's diagnosis/rule out. (requires 2 hour hospitalisation)

- Monitor for signs of hypoglycaemia (lethargy, wobbliness, tremors, vomiting)

Meds/Tx:
- Bravecto spot-on flea treatment (6 monthly) - no swimming or bathing for 72 hours post-application
- Worming treatment administered

REVISIT:
- Vaccinations and heartworm injection due 16/4 - client prefers to return in one month
- Return in one month for due vaccinations, heartworm injection and routine blood work
- Collect urine sample within next few days to confirm glucose levels
- Consider thyroid and Cushing's testing options - estimates to be provided

Interstitial Glucose 
24/9 Average 16.4 Range 9.0-23.2 NADIR @ 11am
25/9 Average 18.9 11.6-22.2 NADIR @ 9am-6pm
26/9 Average 20.9 Range 9.9-25.2 NADIR @ 12pm

Spoke with Ina - they decided to transitioning him to Diabetic dry food. Currently mixing both old and new food. 
Owners will be away in Japan from 19/10/25 - 4/11/25 (Melbourne Cup)

Plan:
When Os return from holiday and diet stable (solely on Diabetic dry food) will monitor with new sensor. 

Interstitial Glucose 
Monday Average 15.1 Range 7.2-20.9 NADIR @10:30am
Tuesday Average 5.7 Range 4.3-7.9 NADIR @ 1:45pm
Wednesday 8.4 Range 2.9-14.7 NADIR @ 12pm

SMS 18/9:
Hi Ina, 
I have been pretty happy with Milo's scans lately. Will be interesting to see after tonight's scan. 
How is he?
Any changes you have noticed?
Kind Regards, 
Dr Pey @ Middle Brighton Vets
---
Hi Pey, To me he seems just normal, sleeps a lot but nothing concerning. 
I'm just wondering whether it could be his dry food causing glucose to spike? 

I've just seen on the pack that there is a total carbohydrate of 45%