Suspected Depo reaction... yup, that junk got another one

mackiemac

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I took out 10 year old Tonkinese named Schrödinger (herein referred to by his nickname of "Boo") to the vet on Monday for what seemed to be a little respiratory crud. His meow was hoarse and he just seemed a little bit out of sorts. He had also been on long term meds for suspected HCM, but his most recent check on that status showed no presence of HCM as reviewed by a board certified cardiologist. (Bolded because this may be important).

Other than sounding a little croaky and basically just chilling out more instead of cruising around the house like he usually does, he seemed pretty much okay. He was eating and drinking just fine-- ravenous as always. He would quickly respond to a dangled toy, his eyes were bright and alert, he was still jumping up onto my shoulders and sitting on the computer desk like normal. But the hoarseness and reduced activity were enough of a concern and there is the concern that his bug might be contagious, so I took him in to be safe.

The vet did a cursory exam, then decided to give 2 shots: one was a "long acting antibiotic" (which I knew to be Convenia-- I refused to allow it, so he did NOT get that one)-- the other was what the doctor referred to as an "anti-inflammatory".

Now, I have almost 25 years of experience working in vet hospitals, from receptionist to 'tech' though I am not a licensed RVT-- but I did all the work of one. The word "anti-inflammatory" immediately conjures up drugs like Metacam, piroxicam, etc. which we HAVE used with caution but also with good safety in the practices where I worked. My fault, I suppose, but because the link was SO strong in my mind that I didn't question what it was, EXACTLY, that my cat got.

Now-- a little back story: Last year Skye, our 14 year old Birman mix, went to the same clinic for her 6 month senior bloodwork. The vet (a different doctor that time... I'll refer to her as "Dr. F" for Female) noticed that Skye was in the midst of a flare-up of her chronic skin allergy. She has eosinophilic granuloma complex and OCCASIONALLY needs a little pred to get her over the acute phase... just about a 7-10 day long step-down course maybe once a year. This time, however, Dr. F thought it would be a good idea to do a Depo-Medrol shot.

Bad idea. By the end of the day, Skye was miserable. Then she began hiding, going off food, being very lethargic and losing weight. She lost a FULL POUND in 2 weeks. I had her back in that clinic 3 days after the shot because she was doing so poorly. But on those visits, she saw "Dr. Male". Dr. M seemed totally unconcerned about the symptoms. He offered NO further testing, NO treatment suggestions, NOTHING. So we called another vet, a cat specialist that I know quite well and trust very highly. She did a chest and abdominal X ray and noticed what she thought might have been a very slightly enlarged heart. I saw the image myself and the heart did look just a little bigger than expected, but it wasn't "huge". Nonetheless, we got a referral to the diagnostic clinic. She had an echocardiogram and another ultrasound, and the diagnostician gave her a good clean bill of health based on what he saw. This is a top-notch doctor as well, and I highly trust him. He did say that the heart was "bigger than a usual cat heart", but "not abnormally large" and the function is fine. Anyway... he thought Skye's issue was a bad reaction to the Depo, and he does not like using that drug unless there is NO other choice. Happily, Skye is now pretty much back to her old self-- but it took about 2 months, and for the first week or two after the shot, we thought we would lose her. I told Drs. M and F, "No more Depo", and that was to apply to ALL of our cats.

Back to Boo... when I took him in and Dr. M said he wanted to give the anti-inflammatory, I know I should have ASKED. But I automatically flipped into the part of my brain that understands "anti-inflammatory" as drugs like Metacam, Advil (I know... not a cat drug), Rimadyl, ketorolac (Toradol)... etc. I do not consider Depo to be an "anti-inflammatory", even though that's one of its functions. I consider it a STEROID, and that is exactly what it is. The word that the doctor used to describe the shot was misleading, and as I said, my "vet worker" mode-brain took me somewhere else... like, to medicines that ARE actually anti-inflammatory drugs and NOT steroids.

HAD THIS DOCTOR UTTERED THE WORDS "DEPO", OR "STEROID" OR "CORTICOSTEROIDS", OR SOME OTHER WORD THAT MORE HONESTLY AND ACCURATELY  DESCRIBED THE MEDICINE... I NEVER EVER WOULD HAVE AGREED TO THIS SHOT! In fact, I had specified verbally after Skye's experience that I did NOT want any of my cats to have Depo-Medrol ever again UNLESS there was absolutely no other choice. So I feel that this vet was dishonest when he used the word "anti-inflammatory" rather than the true drug class-- steroid.

Now it is Wednesday. Boo is hiding under the sofa. He won't eat. He won't drink. He cries when I pick him up. He won't purr and he is "the best purr-er in the whole world". He won't play. He just looks like he wants to cry like a human baby.

On top of that, this vet prescribed BAYTRIL... another medicine that I will not give to a cat because of the risk of serious side effects. By this time, I was so disgusted with the whole matter that I just took the bottle of pills, paid the bill and left. I did not give any of the Baytril, and I'm looking for another vet that I can take him to. I don't drive so it has to be somewhere that I can get to by cab without shelling out a HUGE fortune. Unfortunately the cat vet is quite a distance from me and a cab ride would cost well over $35 just one way or $70 round trip-- there is a bus, but it would require 2 transfers and take over an hour one way, which would just be too stressful on the cats. So... I am limited as to where I can take him now.

I have a call into the treating vets' clinic and am waiting for a call back. 

In the meantime I did a little investigative work-- Dr. M has at least ONE serious reprimand on his license record that I was able to see. This vet took over the practice after the original founding vet, who was our family's vet for 20 years, passed away a couple of years ago. Dr. A would NEVER HAVE given Depo and Convenia to Boo or Skye for something like this. His treatment would have been something like Clavamox and the suggestion to let the cat hang out in the bathroom with me while I take a steamy hot shower and let him breathe the moist air. I am now very upset-- the action on Dr. M involved a case where a d*g had bloodwork prior to a dental, and was told by the d*g's owner NOT to sedate the animal if there was ANY abnormality. There was an elevated WBC-- an abnormality-- but the vet went ahead anyway. The pet died under anesthesia minutes after it began. Further, the vet claimed that the pet was sent for "private burial" but that was also a lie-- the pet was communally cremated. Dr. M was reprimanded by the state's Veterinary Medical Board... NOT for going ahead with the anesthesia contrary to the client's request that the anesthesia not be done if there were any abnormality (the vet chalked up the high WBC to gingivitis... and that may be true, but did he actually call the client to discuss it? Not mentioned in the court document)-- but because he "countered" his own record by saying that the pet was sent for communal when it supposedly said on the record "private burial" and the owner planned to pick up the body but he was denied the ability to do so).

I apologize that this is so long-- but I am now quite concerned. I do not have adequate transportation to another vet for follow-up. If I have to get this cat to "a vet" for urgent care, this is the only choice that is nearby and I can get there reasonably fast. But I really do NOT want these people touching our cats again! I am able to do home supportive care like syringe feeding, SQ fluids for hydration if I can get a bag and 'set-up' from this vet (I am excellent at doing SQ's) and such. But I don't think I want these people touching another cat.

Also-- would any of you file a complaint based on the way the doctor misled even an experienced vet worker by referring to Depo as an "anti-inflammatory" rather than calling it the "STEROID" that it actually is? He never even mentioned the NAME of the drug! I didn't find out it was Depo until I saw it on the receipt!

Again, my apologies for the long post-- but I hope that I can answer some questions from the get-go, and provide enough background to help the "smart paws" here.

~MackieMac
 

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I've never had a cat have a reaction like that to depo.  It usually makes them feel better and improves their appetite.  Your cat's behavior sounds more like a classic Convenia reaction. I don't think you can file a case against the vet for calling depo an anti-inflammatory because that is one of its primary functions, and you didn't ask the vet "What KIND of anti-inflammatory" which would have been simple enough to do.  Just as the vet said "long acting antibiotic" and you declined that because you KNEW it was Convenia, if you didn't know what the anti-inflammatory injection was, I'm surprised you didn't ask since you are so knowledgeable.  After years in rescue, I too have a lot of knowledge, and I always ask about any medications and clearly say no NSAIDS and NO CONVENIA.  When we had paper charts, those instructions were on there.  Now one has to make sure they get on all the electronic charts.

I do hope your cat feels better soon, and I'm sorry you are limited in your choice of vets because of transportation issues.  Normally I recommend people to seek out an AAHA hospital because they are required to have  continuing education and have to meet certain standards to maintain their accreditation.  Here is the link to see if there are any AAHA hospitals anywhere in your area.

https://www.aaha.org/pet_owner/about_aaha/hospital_search/default.aspx
 
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mackiemac

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I've never had a cat have a reaction like that to depo.  It usually makes them feel better and improves their appetite.  Your cat's behavior sounds more like a classic Convenia reaction. I don't think you can file a case against the vet for calling depo an anti-inflammatory because that is one of its primary functions, and you didn't ask the vet "What KIND of anti-inflammatory" which would have been simple enough to do.  Just as the vet said "long acting antibiotic" and you declined that because you KNEW it was Convenia, if you didn't know what the anti-inflammatory injection was, I'm surprised you didn't ask since you are so knowledgeable.  After years in rescue, I too have a lot of knowledge, and I always ask about any medications and clearly say no NSAIDS and NO CONVENIA.  When we had paper charts, those instructions were on there.  Now one has to make sure they get on all the electronic charts.

I do hope your cat feels better soon, and I'm sorry you are limited in your choice of vets because of transportation issues.  Normally I recommend people to seek out an AAHA hospital because they are required to have  continuing education and have to meet certain standards to maintain their accreditation.  Here is the link to see if there are any AAHA hospitals anywhere in your area.

https://www.aaha.org/pet_owner/about_aaha/hospital_search/default.aspx
Nope, no Convenia... and I just BLANKED on the anti-inflammatory. I already have issues with this vet for various reasons (all internal, haven't expressed it outwardly)... I said that I should have asked when I made my first post. I made a mistake. But really, it wouldn't have done much good because he made that remark at the MOMENT he was giving the shot. The needle was already in Boo's shoulder skin and the drug was going in as the vet was speaking. But he DID NOT have Convenia.

My files DO say NO DEPO. Oh, and I also noticed that the cat acts like his mouth is sore. He does have a broken fang, which I mentioned. I asked the vet about it today, since I notice some drooling and chewing avoidance on that side-- the vet NEVER NOTICED the broken fang, never remarked on it. Today I called back-- he told me today that he never noticed the fang. Um, he opened that cat's mouth. I saw it plain as day. And they will not switch the antibiotic from Baytril to another one despite my concerns (have seen cats go blind or have other serious reactions to that one, too).

So, there was a lot going on quickly, I blanked for just a SECOND, the Tonk cat got Depo, the other cat got Depo last year, neither one got Convenia, and both have had the exact same response. Do you still think this is a Convenia reaction even though neither got Convenia? Should I perhaps pursue it as such? You seem to think I'm wrong... and you are right that DM "USUALLY" works wonders and makes them feel a ton better. Except... when it doesn't.

I guess...now all I can do, I suppose, is ask him WHY he gave Depo when it IS on the record. I saw the receptionist type it in, and the tech wrote it on the chart.

There are AAHA hospitals in my city, but as I said, I cannot drive. I would have to travel a long distance by an expensive cab, to the tune of about $70 for the trip to the one I prefer to use-- who happens to be a feline specialist. I have no issue with spending money on treatment for my cat... but the extra $70 just to get there and back every single time is nuts. A $5 bus ride would take way too long and be too stressful with 3 vehicles (2 transfers) and a sick cat.

~Mac
 
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mackiemac

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Oh, and BTW.. a board certified cardiologist and diagnostician at a VCA facility last summer told us that Depo can indeed cause issues like this. He saw our other cat when she had this post-Depo problem last summer. The cat in question has a suspected case of HCM. THAT is all over the record. And since I mentioned it first thing and the vet still gave the Depo... perhaps I am guilty of not asking but HE is guilty of not listening to me and reviewing the cat's history. They even filled atenolol for him some time ago when his cardiologist (HELLO! The cat sees a cardiologist twice a year-- and THIS doc cut the referral!) was out of the office. The cat is on a trial now to see how he does without the atenolol since we began it almost 10 years ago and he is doing wonderfully. Or-- he WAS, until he got Depo.

Any vet worth his salt should have been leery of giving Depo to a cat who has a history of treatment for cardiomyopathy. I did tell the vet that part RIGHT off, in case the illness might have something to do with his heart. Since the cat is sounding a bit better with his meow today and is less watery sounding, I don't think it was his heart making him sick before we went in.

Now... I have to wonder.
 
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mackiemac

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Just to clarify: Neither cat received Convenia. Thus this is absolutely not a reaction to Convenia. His voice is getting better and better as the day goes on, and he got a bag of SQ fluids (Lactated Ringers' solution), 75-100 ml every day or every other day as needed. He also got some mirtazapine to use as an appetite stimulant.

I gave his first round of SQ fluids this evening, and he seems more perky now, and I spotted him eating a little wet food on his own without prompting. It wasn't a lot-- but it was voluntary, and who knows how much he really ate while I was out of the house. He will still get a couple of syringes of baby food before bed, just to see him through the night. I think he was a bit dehydrated, which makes you feel pretty bad. Then he didn't feel like eating. So it's my hope that the first dose of fluids will help him feel better and he'll begin to feel more like eating again.

His voice also sounds a LOT better. But understandably, he's a bit peeved at me for having to make a fuss over him. He WILL get over it, though... he's a very forgiving cat and he never stays mad at me for very long. :)


 
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mackiemac

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UPDATE: Schrodie got a round of SQ fluids last night and today, he is a LOT better. He's not 100% yet, but he's a whole lot more active than he has been, and he's even eating better on his own. He hopped up on the commode to beg my DH for some brushing, too. But he's still not quite all back yet, as he seems to tire out and want to go back into his room or sit down somewhere. But instead of going to the closet-- he went to the window sill in the living room where he likes to watch the birds. So he is getting some interest back, too. 

I think it's just going to take time and some loving support, but it looks like he's turning around. 


Next step: CHANGE VETS
 

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FYI I didn't mean I thought he DID get Convenia, just that I have seen that sort of reaction to Convenia and not to depo, but that's just my own experience.  And yes, if the depo was already being injected when you asked, then too late.  As for the problem with not driving, you might do well with hiring a functional senior citizen cat lover such as myself to drive you to vet appointments and other things.  A lot less expensive than a cab, and those of us living on Social Security retirement are always eager to supplement our income with a little cash for services performed.  
  Could be a win-win situation.
 
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mackiemac

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 As for the problem with not driving, you might do well with hiring a functional senior citizen cat lover such as myself to drive you to vet appointments and other things.  A lot less expensive than a cab, and those of us living on Social Security retirement are always eager to supplement our income with a little cash for services performed.  
  Could be a win-win situation.
That's a really good idea-- I could post a shout out at my church to see who might be willing to do something like that, exchange a few phone numbers, and if I have enough notice, such as for an appointment at "2:00 tomorrow afternoon" I can call someone on my list to see if they'd be able to help out. We have lots of active retirees in my parish, so that's definitely a possibility. Thanks for the idea! Unfortunately there aren't many such folks like that here in our working class/young neighborhood, although my neighbors ARE nice and would help if they could.

UPDATE: Schrodie is really going down again. He's hiding a lot and won't eat again. He has no fever (temp 100.7 rectal), but he's drooling a little. His breath is smelling pretty bad, too. I don't like this turn, and there was the issue in the past with his heart and the inconclusive DX (tentative) of HCM when he was a kitten. He had been on atenolol for a number of years on the presumption that he MIGHT have a very mild case. He had a number of echocardiograms over time and even a couple of cardio specialists couldn't decide "yea or nay". So we went on the side of "yea, but very mild" and did the meds. At age 8-9, onit was decided by his vet at the time that we could see how he did without the atenolol. He has been flawless up to date. BUT... Depo can awaken "sleeping" heart issues. I'm very concerned that this might be the case. 


Then again, with that broken fang and gingivitis-- he may simply be in pain. He does seem to act like "something hurts". I can see it in his face, and the way he eats when he does try to eat. I know that the fang isn't a chewing tooth, but it does have a BIG pulp and nerve chamber and LONG root. I also know from personal experience how painful a bad tooth makes the whole mouth feel. And as a Siamese-family breed, he's subject to gingivitis and dental issues. It could be that as well.

I have an appointment set up for a second opinion at another vet tomorrow afternoon, and a good 24 hour vet with a specialist center upstairs on speed dial if anything happens overnight. That vet is 10 minutes away. Now, if DH didn't have to travel so much for work, it wouldn't be such an issue. Thankfully, he'll be coming back from a trip tonight (3 hours till his flight lands, whee!) so he'll take us there tomorrow.

I'll know more after that time... 


~Mac
 

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I hope you can get your kitty on the road to recovery.

We have had a few kitties here who have had a bad reaction to Depo..  The bad thing about it is that it stays in the system so long and nothing can be done but wait it out.  My  kitty is on a low maintenance dose of Prednisolone but there isn't the issue of staying in the system the way Depo does.  The only thing I would consider Depo for is the autoimmune anemia.  For some reason it will work for that where other steroids don't work.
 
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mackiemac

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Good morning, Denice and thanks for your insights. Like I had said, I too am no fan of any long-acting injectable medicine in most instances-- whether it's for my pets or for myself. That's because you "can't call back a bullet" once it's been shot, and that "Depo bullet" lasts a very long time.

This morning he seems a bit perkier. He ate some breakfast-- just a little but he did eat on his own. He hopped up on the commode and insisted on being brushed a little bit. However, he seems tender to the touch, like he might have body aches. He's been a bit peevish even to a light touch since the shot. That's odd. But he is purring, and what a strong and happy-sounding purr it is! His nose is also moist again. He had been "dry" on the nose leather, but now it was cool and moist-- or as we call it, "ishy". Ishy is good... it is not the same as runny... bad.

He is also trained to do certain "tasks" (dogs do tricks, cats do tasks--LOL!): "Speak", Shake hands... "Left paw/right paw"... "Show your nose/head/paw/tail/whiskers..."... "Sit up handsome"... and he is doing those again. He is quite smart and very eager to show it off when he feels fine. He's also starting to twine around my legs again, and he even slept on my feet for a little while last night. So these are all very clear signs that at least for the time he feels somewhat better

But his breath and face are still QUITE smelly. It smells like infection, not kidney/urea smell like renal failure. I know that smell all too well. The stink on "Dipsh**" (another affectionate nickname) is the same smell that I experience in my own nose when my chronic sinus infection starts up (sorry if that was TMI... but constant Texas allergies means constant ick, means constant sinusitis in my case... and pulse therapy on ABs).

I think the underlying or originating illness that sent him to the vet in the first place is actually a dental problem. In which case, Baytril would not have been the drug of choice. If I was the vet and noticed a broken fang and gingivitis (NONE of which this vet noticed even though his gums are inflamed and red and he has a broken upper fang that I had mentioned months ago on his vaccine visit-- again, ignored just like Skye's half pound weight loss in less than a week!)... I would have considered Antirobe or doxycycline to control the infection for several days to a week-- then schedule for dental services. And CERTAINLY no Depo in a cat who is noted to have a hx of suspected cardiomyopathy!

Nonetheless, we're keeping the second opinion visit this afternoon. While this is not an AAHA/AAFP practice-- they are highly respected. We take Tara there for grooming and they do a great job. Now let's see how they do with medical issues. So far the ratings on Nextdoor for my area are consistently excellent, lots of recommendations and I have always heard good things from other folks when I was still actively working for vets around here (had to quit due to health issues of my own). If I'm impressed, we may switch vets to this one. Otherwise, we're switching to the feline doc. I'd do the cat doc right off but it's much harder for me to get there in a pinch... I have to take that into account since I don't drive.

Wish us luck!
 
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UPDATE (again)... Schrodie is acting VERY normal again. He's eating wet food quite well now, though he's still not hitting up his dry food very much. He's cruising the house again, talking to me in a normal and LOUD voice, jumping up on his favorite window sill... he even came up on the bed with me for a few minutes and made biscuits. He hadn't done that for a few days, and he's a real biscuit maker! He's facial-marking his favorite spots again, which he hadn't done for a few days, either. He's even grooming-- though his saliva smells horrid and it makes HIM smell bad.

I'm really thinking that he has a mouth or tooth infection, perhaps from that cracked fang, or from general Siamese gingivitis. I can't really get a good look in the back (most of us can't see well in the back of our cats' mouths anyway!), but I do see a fair bit of gingivitis around both second premolars (teeth 106 and 206 for those who are familiar with the 3-digit dental charting system... the tiny premolars "outside" the fangs). It is my experience from many, many feline dental cleanings and exams as a tech that this tooth is often affected by cervical lesions (FORL's), and as those progress into the tooth, they can be very painful. Of course, the usual course with any FORL tooth beyond the most superficial stages is extraction, as the condition is progressive and there is no truly effective treatment. At least the P2 is a tiny tooth with little roots, so if a dental exam shows FORLs, an extraction won't be so bad. If that broken fang has to go-- that's another level of pain, but we can manage that.

Because he is now acting so much more normal and is not acting weak, I am less inclined to think that his heart is in bad shape. However, we'll check into that as well just to stay on top of it. And he is due now for senior wellness blood work (every 6 months) so might as well get that done too while he's in. Today's visit will not be a wasted trip-- at the very least, it will be an "interview" for a new vet.

I still do not want Depo for my cats ever again unless it's a matter of life and death. 

Now Skye, on the other hand... our almost 14 year old... is hiding under the sofa now, yet she's eating and drinking and acting normally otherwise. Her meow sounded a bit weak an hour ago, too, but her eyes are clear and bright and she doesn't smell bad like Schrodie does. Hmm, wonder if there IS a small URI going around the house. Or, it could be her skin allergies or her EGC flaring up... or her arthritis kicking in with storms on the way...

Man... never a dull moment with these guys!
 
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mackiemac

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UPDATE FOLLOWING VET VISIT: Well, it looks like we have a new vet. We ran blood work and she did a very good exam on Schrodie. His blood results look quite good overall. The main values of kidney, liver, glucose and thyroid are all well within normal limits-- he looks great in that regard. As for his heart, since he has been "on watch" for over 2 years after stopping atenolol and has had zero issues, chances are good that his heart is strong. He's almost 11, and hasn't had issues, and even the depo didn't kick him over into CHF so his heart is probably not a major concern.

The CBC did show a very high WBC count, mostly neutrophils. So, he does have an infection. 

My gut instinct was correct: he has stomatitis. It isn't as "hamburger-like" as it is in many patients, but he has had Depo recently which might be calming things down a little and making it present less red and angry as it would have been otherwise. It also explains the stinky saliva and the drooling. The fang is also definitely cracked to the pulp chamber, so that's probably also painful. The stomatitis is most likely an autoimmune condition..lymphocytic-plasmocytic stomatitis, which is more frequently found in Siamese-type cats. This was on my mental list of possible issues, so I guess I still have my "mojp" as far as sussing out what might be wrong with my critters!

Since he hasn't been eating and drinking like normal, he has some hard, dry stool in his gut. We are to continue SQ fluids, 150 ml/day for 3 days and give some Laxatone... he will LOVE that! He really thinks it's a treat. His potassium is also a little low, so she sent home some potassium chloride to add to his fluids. She changed the antibiotic to Clavamox twice daily. We discussed AB's at pretty good length and her feeling was that the Baytril alone was probably not the ideal choice in this case... and that her choice would be Clav or Antirobe (clindamycin). And he'll probably go on pulse therapy with Antirobe as soon as we get his tracheal infection cleared up.

She recommended that once we get him squared away and back to "normal", he should return for dental work. He probably needs that fang extracted, and to get a better assessment of the rest of his mouth and teeth... check for FORLs... etc. He doesn't have a lot of tartar because we do brush his teeth several times a week (he loves the kitty toothpaste!), but he's been touchy lately so I haven't done it as much. Now I know why.

This isn't exactly "GREAT" news, but it's at least a manageable problem.

I appreciate the way the doctor took time to converse with me on a professional level rather than treating me like a person who doesn't know anything. Her eyes lit up when I mentioned that I had a lot of years as a vet tech and other positions in veterinary hospitals (I've also done kennel work and reception/customer service). Heck, that looks like a practice where I'd like to work. 


She also was not happy when I told her how the other vet referred to Depo as an "anti-inflammatory", rather than just calling it Depo-Medrol and explaining the reason. It would have been better to say, "I would like to give your cat a shot of Depo-Medrol to help with inflammation", rather than use a vague and yes... misleading term (to someone who calls DM as "a steroid to control inflammation"). That would have given me a better chance to object. 

She did some "real medicine" on my cat: appropriate exam with blood work, and determined a conservative course of treatment. I feel like the other vet basically "shotgunned" Schrodie and he doesn't seem to listen to our concerns. Nor did he offer ANY deeper testing, imaging or anything for Skye when she became very ill after her shot last summer and lost half a pound in a week. I feel that Schrodie got better medicine and assessment at this other clinic than he did at the old clinic. The price is similar, but unless the cost is outrageous... I would rather pay a bit more for GOOD medicine than save a buck for what I feel is comparatively shoddy doctoring. 

Next step: get him feeling better, and dental work as needed.
 
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