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Vet
Vet, Veterinarian
Category: Vet
Satisfied Customers: 83
Experience:  I have spent many years in mixed practice, dealing with all the major species.
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I have a 16 year old male Persian cat who had a pleural effusion

Resolved Question:

I have a 16 year old male Persian cat who had a pleural effusion and his chest was drained last week. The cause is unknown as the fluid was clear, the ultrasound and x Ray showed nothing obvious. The only area of concern was that the blood tests pointed to a heart related issue and he was given medication disease. My vet and a specialist unit were adamant that this was the cause of the fluid build up however after insisting on seeing a cardiologist who undertook further scans, the heart was found to be perfectly normal. I have brought my cat home and he seems to be getting stronger each day and is eating and drinking however my vet has noted on my file no further tests are to be carried out and he appears to be largely uninterested in treating my cat further. He has prescribed prilactone, fortekor and stomorgyl 2 but has not answered my questions regarding follow ups i.e monitoring the chest or blood tests to check his kidneys are working adequately (as my cat has kidney disease). I feel that as my vet has mis diagnosed the condition, he does not know what to do cat and has essentially given up on him despite his continuing improvement over the last few days. Also approximately 10 days earlier my cat had a routine blood test to monitor his renal function however something went terribly wrong and his whole leg started to swell. My vet said he likely touched a nerve but the swelling would go down. A week later when I returned to the vets, this was when the heart problem was suggested as being the cause of the swelling and that was when an ultrasound was performed and fluid found. I do not know what has caused the fluid and what to do if or when the fluid recurs. All I know is that I should monitor his breathing which should be below 35 breaths per minute. His breathing is currently between 20 and 24 breaths however his breathing has never been "normal" as he has had a polyp in one of his nasal passages 7 years which is by and large under control. My fear is if or when my cat deteriorates, they will suggest putting him to sleep as was suggested when the mis diagnosis was made. Thankfully I had a gut feeling that the diagnosis was incorrect and I was proved to be right and my cat as I mentioned is improving. Can you suggest a way forward as I don't believe we are receiving the right information and if I change vets I worry that the existing notes will be followed.
Submitted: 2 years ago.
Category: Vet
Expert:  Vet replied 2 years ago.
Vet :

there, vet Andrew here.

Vet :

It seems that Simba is a complex case, and I understand your worry. However, there is a clear procedure that you can follow if not happy with your own vet. I will explain it to you.

Vet :

First, you have no obligation to contact your own vet any further, although you are of course welcome to make a complaint to the senior partner of the practice. You should do it in writing and clearly set out what you feel is wrong and what you want done. If there is another vet in the practice, especially the senior partner, who you would like to take on the case then request that.

Vet :

Alternatively, you may without notice take Simba to another practice.

Vet :

It is then the duty of the new practice to request and read through Simba's notes before your initial consultation.

Vet :

If Simba is insured, or your finances permit, I would recommend taking him to a feline specialist in a referral practice or a vet school.

Vet :

I have dealt with many referrals from other practices, many of which were clients disgruntled with the treatment plan or the vet, and I assure you there is no bias towards following the original treatment plan. Often, you find that a fresh mind on the matter can throw up new plans or ideas.

Vet :

I hope this explanation helps, but please ask away if you wish to know more. Also, you have given a detailed description of Simba's treatment to date. Do you have any questions that relate to his condition or treatment?

Customer: My vet referred Simba to Langford Small Animal Hospital in Bristol however they had already spoken with my vet and agreed that the cause of the pleural effusion was heart related. Upon realising that the Cardiologist found nothing wrong with his heart, the vet in Langford could only suggest a CT scan which meant injecting a contrast fluid into sImba however I was informed that this could kill him because the fluid is toxic to cats with renal disease. I was also informed that if they were to find something it could not be treated. I therefore declined the scan. The only other suggestion was to drain the fluid again if it built back up and retest the fluid as fluid can change. I discussed this with my vet and got the district impression that he no longer wanted to treat simba. Can you suggest any further diagnosis or less invasive tests that may assist in Simba's treatment? How can we know if he has been prescribed the right drugs if we don't know the cause of the fluid? If the problem is not heart related what could be the cause of the high levels in his blood which pointed to a heart condition? what is the significance of the swelling in his leg? I just want to help Simba in the best way I can and just don't know what to do next.
Vet :

OK. Can you remember what type of fluid was found in Simba's chest?

Customer: All I was told was that it was a clear water like fluid.
Vet :

Right, there are a few types of clear fluid, but the possible diagnoses are:

Vet :

Low blood protein - this would have been picked up by blood tests already.
Heart failure - as discussed, it's probably not this
Pleural adhesions - scar tissue between the lungs, seen on CT scan and cured by surgery, which, of course, is highly invasive
Twisted lung lobe - should have been picked up on X-ray
Tumour or hernia - Again, picked up by X-rays.

Vet :

The treatment pleural effusion, other than by drainage, is to tackle the underlying cause. In Simba's case, it looks like there is conflicting information about his heart, and your vet is covering it in case it is a factor. The only other item on the list is scar tissue, which requires CT and surgery, and I fully understand your reluctance to put him through that.

Vet :

My feeling on the heart issue is that ultrasound is not everything, and if a blood test found evidence of heart muscle damage (I asssume this is the case), then I would treat as failure.

Vet :

Simba's leg swelling was likely due to a blown vein, which can be quite severe in older animals. As long as it goes down over the following few days it is nothing to worry about.

Vet :

To conclude, I feel that Simba's effusion is either heart-related or what we call idiopathic, i.e. no known cause, which can happen in Persians. The likelihood is that he will get one again, which will require drainage. The idea with therapy in these cases is to maximise the time between drainage sessions to improve Simba's quality of life.

Vet :

The Fortekor is to reduce strain on the heart and improve pumping efficiency. The Prilactone is a diuretic to reduce fluid build-up, and the stomorgyl is to cover . These seem like reasonable drug choices, although the stomorgyl may not be needed long-term. If I were your vet, I would X-ray Simba regularly to monitor in his chest, too.

Vet :

Simba's breathing rate will be a rough guide much fluid is currently in his chest.

Customer: Simba's protein levels were low however my vet said it wasn't low enough to create this problem. I am having difficulty trusting anything now due to the many errors that have already been made. Any professional that has ever treated Simba has always indicated that he is not a typical cat and may be affected differently which makes me wonder whether the protein level is actually an important factor which has now been dismissed.
Vet :

How low was the protein?

Customer: i don't know the exact figure but was told it was the low end of normal. The stomogyl 2 is diarrhoea he has suffered with after being in the emergency unit days. He only started eating when I brought him home so I assume it was trauma related and the shock of having food. He is taking 1 prilactone tablet 10mg daily. Is that a sufficient dose in your opinion? His breathing ranges from 20-24 breaths per minute. At what point should I begin to worry? Simba did not react to the sedation very well but was discharged none the less and I had to return him to the emergency vets where he stayed days. He has had an ultrasound without sedation before, perhaps you could advise how often this should be undertaken so that he may be monitored accordingly.
Vet :

Prilactone is actually , so the dose is slightly experimental. You may find a dose increase, or a switch to twice-daily dosing may help, but do this in communication with your vet.

Vet :

The normal range is 16-40 breaths per minute, so I would put 40 as his upper limit.

Vet :

As ultrasound, if he tolerates it well then I would try a monthly scan monitoring.

Vet :

The scan will also help with adjusting his Prilactone rate.

Customer: What is your view on the protein levels if Simba is at the low end of normal. I know his potassium levels are also low and he is also anaemic if that helps in any way. I also assume this lower level of prilactone has been prescribed because of the kidney disease?
Vet :

I would say that the protein level may have contributed to the effusion once it started, but would not on its own have caused it. There are plenty of older cats with protein levels below normal who do not get effusions. The low protein, potassium and anaemia are likely related to the kidney disease. Sometimes a six-monthly injection of an anabolic steroid help here.

Vet :

Yes, you have to be careful with diuretics, especially those used off-label, as they can cause dehydration.

Customer: How would I find a top rated vet who will treat Simba and who is a specialist in this field? Would you be able to estimate how quickly the fluid may build back up and advise whether there is anything I can do to help decrease the chances of it recurring. Simba does drink a lot and I assume this has no bearing on the fluid in his chest?
Vet :

The best cardiologists, depending on where you are, are found in veterinary schools, especially the RVC. You may request referral to there. Bear in mind, however, that you are close to exhausting the diagnostic options available. However, a fresh pair of eyes on the case may help.

Pleural effusions all vary but typically need draining every 3 months or so.

Vet :

The drinking is related to the diuretic and the kidney disease. You mustn't let his water bowl go dry or he'll dehydrate quickly.

Customer: As I mentioned, it would appear my vet has given up on Simba despite his improvement, so if I change vets how would I find a top rated vet who specialises in this area and chest draining or are all vets able to do this?
Vet :

All vets can drain a chest. I would take Simba to a good local practice, then request referral from there, as you are clearly not happy with your current vet. The new vet can do the chest draining and any other standard treatments while the cardiologist works on the case.

Vet :

I think I've advised you as far as I can, because the next stage is to switch practice, get Simba re-assessed, and discuss referral. Please bear in mind the extent to which Simba has already been investigated, and use this to tailor your expectations of what the new vet and specialist are able to do. As long as he is improving, you may already be on the right track. I do appreciate your need fresh opinion, however.

Customer: Can you just tell me whether there is a sedation that can be reversed quickly and would benefit Simba as he was so slow to recover? I was once told that there was such a thing however my current vet says there is not. I have also read that pleural effusion can itself be created as a result of renal disease, is that correct? If I think of anything further, am I able to revert back to you. i very much appreciate your thoughts and advice thus far.
Vet :

there, sorry I was called away moment. There is medetomidine which can be reversed, but has to be used carefully in kidney patients.

Vet :

Renal disease can cause protein loss to such an extent that a pleural effusion happens, but only in severe cases. The blood protein would have shown up as very low and Simba would have likely been emaciated as a result.

Vet :

As back to me, I can schedule a further service with Just Answer once this session has been closed and rated. I have not used this feature before but it should provide further opportunity to ask me questions. I am glad to have been of some help.

Customer: I haven't used this site before so am unaware how the further service works. What do I have to do?
Vet :

I haven't used it either, but it is a new feature of JA which you can use to contact me. You'll be sent details of how to use it.

Customer: Ok I'll wait to receive the details. In the meantime thank you help.
Vet :

No problem. Just to be clear, you need to rate my answer so this session can close and give me the option to offer the extra service. Regards, ***** *****

Customer: Will do. Many thanks.
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