VETERINARY MEDICAL TEACHING HOSPITAL TEXAS A&M UNIVERSITY ONCOLOGY RECHECK APPOINTMENT REFERRAL LETTER/DISCHARGE INSTRUCTIONS OWNER NAME/ADDRESS: Alison A Loughlin PATIENT: Nunya ADMISSION DATE: June 21, 2013 DISCHARGE DATE: June 21, 2013 REFERRING VETERINARIAN: ATTENDING CLINICIAN: STUDENT: SENIOR CLINICIAN: PROBLEM(S) FOR WHICH PATIENT WAS PRESENTED: Recheck nasal carcinoma - CT scan PLAN FOR RE-EVALUATION: Nunya will need a CBC checked in 7 days and again in 14 days from today to check her blood cell counts to assess her response to today's chemotherapy. You may have these performed with ****. Please have the results faxed to us at Attn: Oncology.
Please schedule an appointment for Nunya for her next dose of chemotherapy (doxorubicin) for 3 weeks from today (7.12.13). ALL CURRENT MEDICATIONS NAME, SIZE & INDICATION INSTRUCTIONS & DRUG INFORMATION
Give 1/2 tablet by mouth every 8 to 12 hours for nausea.
adenosylmethionine/silybin) Ursodiol 250 mg tablets #15
chemotherapeutic DISCONTINUED DISCONTINUED- replaced with
adenosylmethionine) 225 mg support liver
HISTORY SINCE LAST APPOINTMENT: Nunya is a 13-year old mixed breed spayed female who was presented for a CT scan to re-evaluate her nasal carcinoma. Nunya's owner reports that she has been sneezing more frequently with small amounts of bloody discharge being present. Two 2-week courses of Clavamox did not improve the the discharge or sneezing. Nunya has otherwise been comfortable at home and is eating and drinking well. She is currently receiving cyclophosphamide, furosemide, ursodiol, Denosyl and chlorpheniramine. ABNORMAL PHYSICAL EXAM FINDINGS: Wt. 12.7 kg T: 101.2*F P: 114 bpm R: 18 bpm BCS: 8/9 Nunya is bright, alert and responsive on presentation. Her left nostril appears occluded with a moderate amount of dry, crusty discharge present. Nunya has a stertorous sound to her breathing when at rest. Her left eye is consistent in appearence from her last appointment. A small mass was palpated on her caudal thigh which had not been noted in previous exams. Mucous membranes are pink and moist with a CRT<2sec. There is moderate dental tartar on all arcades. Her ears are clean and free of discharge. Her palpable lymph nodes are small, soft and symmetrical. On thoracic auscultation, her lungs sounded clear and her heart beats were strong and regular. She has a history of a murmur but I could not hear it. Her femoral pulses were strong and synchronous with her heart rate. No abnormalities were palpated on abdominal palpation. DIAGNOSTIC TESTS & RESULTS: Nasal CT Scan: CT diagnosis: 1. Recurrence of left nasal carcinoma with bony destruction including early lysis of the cribriform plate and. The tumor extends into the frontal sinus and oral cavity. 2. Thickening of the soft palate appears remote from the tumor and may represent edema. This is unchanged from previous exam. CT findings, nasal, pre- and postcontrast: Images are compared to those made February 12, 2013. The left-sided soft tissue attenuating nasal mass has recurred. The mass extends from just caudal to the maxillary canine teeth all the way to the cribriform plate filling the left nasal cavity. Soft tissue attenuating material extends into the left frontal sinus and left choana. Left-sided turbinate lysis is more extensive/severe. The left major palatine foramen is wider than the right and the tumor extends through the left major palatine foramen into the oral cavity. There is heterogeneous contrast-enhancement of the mass. On image 48/63 of sequence 9, there is a very small defect in the left cribriform plate. There is no evidence of contrast enhancement of the brain adjacent to this region. The soft palate is thickened. This appears to be remote from the tumor and is unchanged from the previous study. The medial retropharyngeal and mandibular lymph nodes are normal in size, unchanged from before. There is a small amount of debris in the horizontal portion of both external ear canals. Cytology: A fine-needle aspirate was taken of the small subcutaneous mass present on
the right caudal thigh. Results indicate the cells representative of a benign lipoma.
Complete blood count: Absolute Lymphocyte
Test Interpretation: Mild lymphopenia consistent with a stress leukogram. Acceptable for chemotherapy. NOVA: Sample Type: Venous. FIO2: 21.0 %. PCV: 55%. TS: 8.0 g/dl
Mini chemistry panel: Alkaline Phosphatase
Test Interpretation: This is a slight elevation in ALP. We will want to continue to monitor liver function throughout Nunya's treatment protocol. The prescribed Denamarin and ursodiol will help serve as a liver protectant.
DIAGNOSES & RESPONSE TO TREATMENT:
Nasal carcinoma- evidence of progressive reccuring growth and infiltration into the
Historical elevated liver values - slight increase in ALP today
TREATMENTS: Nunya underwent a short general anesthesia for her CT scan today. She did well with an uneventful recovery. Nunya also received an intravenous infusion of carboplatin (148 mg diluted in 30 mL of saline) via the right cephalic vein. ADDITIONAL INFORMATION: We are very sad to report that the CT scan performed today showed that Nunya's nasal tumor has recurred. At today's appointment we discussed the available treatment options for Nunya at this time. Since Nunya received a definitive radiation protocol last Fall for her nasal carcinoma, more radiation is not an option at this time. Nunya's tumor has returned in the face of the oral cyclophosphamide metronomic chemotherapy and therefore we recommend stopping this drug since it is no longer working. We discussed two chemotherapy options that would be reasonable at this time: combination chemotherapy with 2 injectable drugs, or an oral chemotherapy that you would give at home called Palladia. Palladia has the potential for causing gastrointestinal upset, lethargy, anorexia, kidney and liver damage as well as bone marrow suppression. With Nunya's history of elevated liver values after receiving meloxicam, Palladia may not be the best option at this time. The chemotherapy protocol using a combination of 2 injectable chemotherapy drugs (doxorubicin and carboplatin) is the recommended treatment option at this time. We hope that Nunya will experience improvement in her clinical signs (i.e. less sneezing and bleeding) with chemotherapy and it is possible that the tumor will shrink. A CT scan could be repeated to evaluate this. Recheck thoracic radiographs to evaluate for metastasis are recommended in about 3 months or after about 2 doses of each drug. We will also want to continue to monitor Nunya's liver function with periodic chemistry panels. The plan for Nunya's chemotherapy is to alternate between the two drugs which would administered once every 3 weeks for a total of 5-6 doses for each drug. This means a total of 10-12 treatments will be given to Nunya as part of this therapy protocol. It is estimated that each treatment will cost between $300 - $400. We started Nunya's chemotherapy protocol today with the drug carboplatin, which is a platinum-containing compound used in treating some cancers in animals as well as humans. Some possible side effects include: 1. Nausea and/or vomiting 3-5 days after treatment. 2. Low white blood cell count, possibly predisposing to infection. Please call your veterinarian or the Veterinary Medical Teaching Hospital if you observe any of these signs. Doxorubicin is the chemotherapy drug that Nunya will receive at her next appointment and is a drug in the antibiotic class used to treat some cancers in animals as well as humans. Some possible side effects include: 1. Gastrointestinal upset, nausea, and/or vomiting, usually 3-5 days after the treatment. 2. Damage to the leg if accidentally given outside the vein. This is prevented by
carefully placing an IV catheter for drug administration. 3.Hair loss in dogs with continuously growing hair (i.e. Poodles, Terriers and Old English Sheepdogs). 4. Low white blood cell count, possibly predisposing to infection. 5. Heart problems if more than 6 doses are administered. Please call your veterinarian or the Veterinary Medical Teaching Hospital if you observe any of these signs. In addition, we discussed the option of entering Nunya into a clinical trial available to patients receiving doxorubicin. The trial is investigating the effects of a probiotic on doxorubicin-induced diarrhea. Nunya would be randomized to receive either a placebo or a probiotic prior to receiving her second dose of doxorubicin. You would be required to record whether Nunya experienced any diarrhea and collect several stool samples. There is also a small incentive for participating in this trial during Nunya's second and third doses of doxorubicin. Please continue to monitor Nunya at home and let us know of any changes you may see in her breathing patterns, nose bleeds, sneezing, energy, appetite or if you have any other concerns. We are hopeful that this course of treatment will help slow the progression of the tumor and provide Nunya some relief. Thank you again for entrusting us with Nunya's care, she is a very sweet girl!
****IF YOU HAVE ANY QUESTIONS OR PROBLEMS, PLEASE DO NOT HESITATE TO CALL:, FAX:, OR E-MAIL: Sincerely,
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Si j’avais su … Bilan de 10 ans avec la Maladie de Parkinson. (Paolo 20.12.07) Né en 1930, j’ai reçu le diagnostic de la maladie de Parkinson au printemps 1997, donc à l’âge de 67 ans. Je ne connaissais cette maladie que par les images de Casius Clay et du Pape Giovanni- Paolo II. Mais je n’avais aucune idée sur l’évolution de la maladie et sur les thérapies à utiliser