C10032184 / invoice 10000

History: Felix is co-managed by the oncology department and internal medicine departments for multiple myeloma, CKD and diabetes mellitus. Multiple myeloma was diagnosed through evidence of Bence Jones proteinuria, persistent serum hyperglobulinaemia and evidence of plasma cell neoplasia on hepatic and splenic aspirates.11/12/25: Urine protein electrophoresis. PROTEIN ELECTROPHORESIS   Sample: Urine   Protein 0.12 g/L.   Creatinine 4.4 mmol/L.   Albumin    0.01   g/L   Alpha 1    0.00   g/L   Alpha 2    0.02   g/L   Beta 1     0.01   g/L   Beta 2     0.00   g/L   Gamma   0.09   g/L***Please see history from 16/12/25 detailing entire protein electrophoresis history***Felix was  diagnosed with diabetes mellitus. See IM history for complete DM summary. 30/12/25: Melphalan commenced @ 1mg PO ETD.6/3/26: QML bloods, serum and electrophoresis performed. Neut 3.5 x109/L (2.1-9.1), platelets: 126 x109/L (200-700), Globulin 48 g/L (29-50).Phone consultation performed today with Williana, EM and EC.Assessment: Multiple myeloma: --> Hyperglobulinaemia, Bence Jones proteinuria, plasma cell neoplasia of liver and spleen (QML cytology) --> Melphalan commenced @ 1mg PO ETD (maintenance dosing) on 30/12/25 Hyperglobulinaemia- improvedBence Jones proteinuria- improvedCKD IRIS stage 2Diabetes Mellitus HypercholesterolaemiaBiochemical hepatopathy:  resolved Treatment: Continue: Melphalan 1mg PO ETD Client Communication: EM phone consultation with Williana Felix was salivating yesterday, Melphalan was due but not given. To be administered tonight. Electrophoresis of serum and urine show improvement with melphalan treatment.Plan: Repeat CBC to assess platelet levels. If still reduced consider change to cyclophosphamide. If normal, repeat CBC, MBA in 2 weeks.Urine and serum electrophoresis due in May 2026. Laboratory: PROTEIN ELECTROPHORESISSample: UrineProtein = 0.09 g/L.Creatinine 8.8 mmol/L.Monoclonal gammopathy. Electrophoresis trace will be emailed to you.- from the trace: Gamma glob 68.7% (6.2-15.4), 0.06g/LPROTEIN ELECTROPHORESISSample: SerumAlpha-1 Globulins 7 g/L (2-11)Alpha-2 Globulins 9 g/L (4-9)Beta Globulin 8 g/L (7-19)Gamma Globulin 29 g/L (15-39)Vetnostics North Ryde NATA Accreditation Number: 14599.Serum sample. Monoclonal gammopathy.Electrophoresis trace will be emailed to you.Dr John Mackie BVSc, PhD, FACVSc, DACVPSpecialist Veterinary PathologistVETNOSTICSHb 98 g/L (103-159) Plat 126 x109/L (200-700)RCC 6.9 x1012/L (5.5-10.0)Hct 0.29 (0.28-0.45) Retic 0.1 % (< 1.5)MCV 42 fL (40-52) Abs. 7 x109/L (< 81)MCH 14 pg (13-18)MCHC 336 g/L (321-368)WBC 4.6 x109/L (4.3-14.4)Neut 3.5 x109/L (2.1-9.1) Neut % 75Lymp 0.8 x109/L (1.6-7.0) Lymp % 18Mono 0.0 x109/L (< 0.7) Mono % 1Eos 0.23 x109/L (< 1.41) Eos % 5Baso 0.05 x109/L (< 0.11) Baso % 1Leucocytes appear normal and mature. Red cells are normochromic with mild anisocytosis and low numbers of keratocytes. Platelets are decreased. Small numbers of Heinz bodies. No clots or platelet clumps are present.SERUM CHEMISTRYFasting status RandomSodium 148 mmol/L (147-161)Potassium 4.4 mmol/L (3.7-4.9)Chloride 117 mmol/L (100-125)Bicarbonate 16 mmol/L (15-24)Anion Gap 19 mmol/L (15-26)Urea + 12.5 mmol/L (5.8-11.5)Creatinine + 276 umol/L (69-160)Glucose 4.2 mmol/L (3.9-8.3)Bilirubin 4 umol/L (0-4)AST 27 U/L (1-60)ALT 78 U/L (1-80)GGT < 5 U/L (0-5)Alkaline Phosphatase 25 U/L (0-80)Protein + 84 g/L (61-83)Albumin 36 g/L (28-40)Globulin 48 g/L (29-50)Albumin/Globulin Ratio 0.8Calcium 2.61 mmol/L (1.90-2.70)Phosphate 1.4 mmol/L (1.0-2.0)Creatine Kinase 182 U/L (0-444)Cholesterol + 5.7 mmol/L (2.4-5.2)Triglyceride + 1.1 mmol/L (0.1-0.6)Total T4 21 nmol/L    Vital Signs    Weight: 7.5;       

History: Felix is jointly managed by ARH oncology and internal medicine for multiple myeloma, chronic renal disease, and diabetes mellitus.Please see previous notes for comprehensive history. His most recent blood results from 06/03/26, a summary of his medical diary and glucose values are reported below. 06/03/26 VETNOSTICSHb 98 g/L (103-159) Plat 126 x109/L (200-700)RCC 6.9 x1012/L (5.5-10.0)Hct 0.29 (0.28-0.45) Retic 0.1 % (< 1.5)MCV 42 fL (40-52) Abs. 7 x109/L (< 81)MCH 14 pg (13-18)MCHC 336 g/L (321-368)WBC 4.6 x109/L (4.3-14.4)Neut 3.5 x109/L (2.1-9.1) Neut % 75Lymp 0.8 x109/L (1.6-7.0) Lymp % 18Mono 0.0 x109/L (< 0.7) Mono % 1Eos 0.23 x109/L (< 1.41) Eos % 5Baso 0.05 x109/L (< 0.11) Baso % 1Leucocytes appear normal and mature.Red cells are normochromic with mild anisocytosis and low numbers ofkeratocytes. Platelets are decreased.Small numbers of Heinz bodies.No clots or platelet clumps are present.SERUM CHEMISTRYFasting status RandomSodium 148 mmol/L (147-161)Potassium 4.4 mmol/L (3.7-4.9)Chloride 117 mmol/L (100-125)Bicarbonate 16 mmol/L (15-24)Anion Gap 19 mmol/L (15-26)Urea + 12.5 mmol/L (5.8-11.5)Creatinine + 276 umol/L (69-160)Glucose 4.2 mmol/L (3.9-8.3)Bilirubin 4 umol/L (0-4)AST 27 U/L (1-60)ALT 78 U/L (1-80)GGT < 5 U/L (0-5)Alkaline Phosphatase 25 U/L (0-80)Protein + 84 g/L (61-83)Albumin 36 g/L (28-40)Globulin 48 g/L (29-50)Albumin/Globulin Ratio 0.8Calcium 2.61 mmol/L (1.90-2.70)Phosphate 1.4 mmol/L (1.0-2.0)Creatine Kinase 182 U/L (0-444)Cholesterol + 5.7 mmol/L (2.4-5.2)Triglyceride + 1.1 mmol/L (0.1-0.6)Total T4 21 nmol/LPROTEIN ELECTROPHORESISSample: UrineProtein = 0.09 g/L.Creatinine 8.8 mmol/L.Vetnostics North Ryde NATA Accreditation Number: 14599.Monoclonal gammopathy. Electrophoresis trace will be emailed to you.PROTEIN ELECTROPHORESISSample: SerumAlpha-1 Globulins 7 g/L (2-11)Alpha-2 Globulins 9 g/L (4-9)Beta Globulin 8 g/L (7-19)Gamma Globulin 29 g/L (15-39)Serum sample. Monoclonal gammopathy.Electrophoresis trace will be emailed to you.Medical diary summary/events of note - see attached for full record  15/2/26: Sluggish demeanour, appetite poor (240kcal intakeof 290-300)16/2/26 - 17/2/26:  Low energy, requiring encouragement to eat20/02/26: Vomited after meal + hairballs in PM26/2/26 - 27/2/26: Quieter than usual ('a bit meh'), appetite mildly decreased 1/3/26 - 3/3/26: Requiring encouragement to eat 6/3/26: Picky, reduced intake (280kcal intake of 290-300)Blood glucose summary (Free-Style Libre) 9/2/26 -  3.213/2/26 - 8, glucometer 6.414/2/26 - 18.1, glucometer 14.2, ketodiastix negative 15/2/26 18.7, glucometer 15, ketodiastix positive for glucose +++ 16/2/26 20, ketodiastix positive for glucose ++++17/2/26 13.1, ketodiastix postivie for glucose + 17/2/26 7.4, ketodiastix negative 18/2/26 17.6, ketodiastix positive for glucose + 19/2/26 12, ketodiastix negative 20/2/26 New insulin pen 23/2/26 11.1, glucometer 8.8, ketodiastix negative 24/2/26 FS Libre removed. Ketodiastix negative Telephone conversation: Joint conversation with EC, EM and Williana. Williana reports Felix is generally doing well - having some worse days than others, but overall doing well. Williana has been weighing Felix every 3 days, his most recent weight is 7.5kg (fluctuating between 6.8kg - 7.5kg). His melphalan dose yesterday was skipped as Felix was noted to have significant ptyalism and was overall lethargic ("sluggish") prior to melphalan administration. Maropitant and ondansetron administered. Blood glucose measured due to sluggishness - 6.1mmol/L. Williana is considering replacing Felix's freestyle libre for ongoing glucose monitoring - we have advised this is appropriate if desired. Williana enquired regarding loss of potency of insulin in pen when nearing end of box-labelled shelf-life following persistent hyperglycaemia (15-25mmol/L) for ~3 days following FS Libre placement and venipuncture despite normal insulin dosing. At this time, the Toujeo pen was close to it's labelled shelf-life date. Discussed that there are some thoughts on bacterial contamination and subsequent loss of insulin potency, caninsulin is anecdotally known to settle out and develop particulate matter if stored for a prolonged period of time. Recommended discarding pens if stored for >6 months. Williana advised the box label for the shelf life of toujeo is 30 days. Discussed possible combined stressors of FreeStyle Libre placement and same-day venipuncture; these procedures have historically been performed separately with no recorded episodes of hyperglycaemia. Discussed that stress hyperglycaemia may persist for several days, however recommend switching pen if seeing persistent elevations in blood glucose when nearing the end of the pens shelf life. Felix's creatinine is mildly further elevated (276 cf 253), discussed that there is known inter-day and inter-test variability of up to 20%, at present, this elevation is not overly concerning and ongoing serial monitoring as planned remains appropriate. Felix likely remains an IRIS stage II, no adjustment to therapy is indicated at present. Felix's most recent UPC demonstrates borderline proteinuria (0.3), at this stage no intervention is recommended.  Mortier et al JVIM 2025 identified more rapid progression of renal disease in healthy cats with borderline proteinuria, however clinical relevance and adjustment of current therapeutic guidelines are unclear. Ongoing monitoring q3 monthly remains recommended, it is noted that Bence-Jones proteinuria is not assessed by UPC ratios and ongoing separate assessment will remain required. Repeat blood pressure monitoring is recommended q3 monthly for comprehensive re-staging of Felix's CKD. Ideally to be performed at home to avoid clinic-associated hypertension. Williana enquired regarding repeat imaging. Felix underwent a CT in December 2025, his last abdominal ultrasound was November 2025. Discussed that repeat abdominal ultrasound is not currently indicated unless a significant progression in creatinine is noted or other evidence of disease progression becomes apparent. Ongoing management of his multiple myeloma will be predominantly guided on the basis of blood and urine results, and given the degree of stress associated with obtaining imaging vs the degree of clinical information obtained, repeat imaging is not currently required or recommended.Williana enquired regarding cardiac toxicity and melphalan dosing. Advised that melphalan is not known to have specific cardiotoxicity in cats, however multiple myeloma in cats may result in hyperviscosity syndrome due to inappropriate immunoglobulin production and subsequent cardiac disease. At present, an echocardiogram is not required. Felix's current diet is a combination of Royal Canin Renal, Royal Canin Gastrointestinal, and Hills K/D. Williana suspects some taste-bud changes have occurred with melphalan therapy; this is a known recorded side-effect in human patients. As Felix  currently does not require strict phosphorus restriction (Phosphorus 1.4mmol/L on 06/03), ongoing feeding of any of the above diets is appropriate. Continued monitoring of Felix's phosphorus will be performed via monthly biochemistry. Given Felix's overall well state and improving hyperproteinemia and hyperglobulinaemia, the current plan is as follows: - Proceed with CBC next week Wednesday (18/3/26). - Pending receipt of these results and adjustment of therapy, likely repeat CBC in 2 weeks- Repeat electrophoresis and biochemistry in 1 month Plan: - Administer melphalan tonight (11/03/26) - CBC on 18/3/26- Await CBC results - EM to adjust therapy as required. Pending receipt, repeat CBC q 2 weeks- Next electrophoresis and serum biochemistry in 1 month - Replace freestyle libre- Continue Toujeo as previously (2 IU BID) - Add weight as column in medical diary - continue weighing q3 days    Vital Signs    Weight: 7.5;