1. RobertGracia Small Animal Clinical Nutrition
AVCID# 106395 August2, 2012
Case 1: Bosco Robinett
Assessthe animal –Bosco, a 3-year old,intactmale EnglishSpringer spaniel,wasrecentlystruckbya
motor vehicle. He hadbeena healthydogpriorto the accident. Bosco sufferedafracturedrightfemur
that wassuccessfullyrepairedbyone of the associate veterinariansinyourpractice. Post-operative
recoverywas uneventful exceptforbacterial infectionof the suture line. A secondminorsurgical
procedure wasnecessarytodraina small subcutaneousabscessandplace adrain. Boscois receiving
parenteral antibioticsbasedonculture andsensitivitytestresults fromaspecimenobtainedfromthe
infectedsurgical site. There isnoevidence of osteomyelitis.
Your currentphysical examinationisunremarkable exceptforthe infectedsurgical siteandmildfever.
Bosco currentlyweighs53poundswithan ideal BCS (3/5). Bosco is alertbutis confinedtoakennel in
your hospital. He isallowedtogointoa small run fora few minutesseveral timeseachdaytoeliminate.
You anticipate thathe will be hospitalizedforatleastanotherweekoruntil the infection iscompletely
undercontrol.
Assessthe foodandfeedingmethod –Priortothe accident,Boscowasfeda grocery branddry dog food
(AttaBoy). Table foodand rawhide chewswere offeredfrequently. Inthe hospital,Boscohasnotbeen
offeredmuchfood because of the multiple surgical procedures. Hisappetite todayappeared
questionable andyouare not sure if he is eatingenoughfoodtomeethisdailyenergyrequirements.
You note inthe medical recordthathisappetite hasbeenpoorwhenhe wasboardedinyourfacilityin
the past.
Atta BoyDog Food Ingredients:Cookedyellow corn,meatandbone meal,cookedwheat,wheatbran,
corn glutenmeal,animal fat(preservedwithmixedtocopherols),brewer’srice,digestof poultryby-
productmeal,poultry by-productmeal,canolaoil,fishmeal,tomatomeal,mineralsandvitamins.
Guaranteedanalysis:Crude protein=not lessthan23%; crude fat = not lessthan9%; crude fiber=not
more than 4%; moisture = notmore than 10%; calcium= not lessthan1% 320 kcal ME/cup Nutrition
statement:Animal feedingtestsubstantiatethatAttaBoy Dog Foodprovidescompleteandbalanced
nutritionforall life stages.
GuidingQuestions1.Whatare the keynutritional factorstoconsiderinthispost-surgical patientwith
secondarybacterial infection?2.Calculate Bosco’scurrent,estimatedenergyneeds(i.e.illnessenergy
requirement). Please show all work. How are yougoingto getthese caloriesintoBosco(i.e.how will
youget himto consume all of the calories)?3.Basedon the current information,whatfood,food
dosage,andfeedingmethodwouldyourecommendforBosco? How doesthisfoodcompare to the key
nutritional factorsyoulistedinnumber1? What wouldyoudoif he refusestoeat?4. What parameters
will youmonitortodetermine isyouare feedingplanisadequate,insufficient,orexcessive? How
frequentlywillyoumonitorthese inthispatientandforhow long? What are your long-termnutrition-
relatedplans(next2-3months) forBosco(i.e.plansforwhenhe goeshome)? Please be specificand
thorough.

2. Case 1: Bosco Robinett
1. What are the keynutritional factorstoconsiderinthispost-surgical patientwithsecondarybacterial
infection?The keynutritional factorswouldbe Highdigestibleproteins,Highdigestiblefats,low to
moderate digestiblecarbohydrates,lowfiber,increasedpotassium,highlypalatable,prebiotics,
probiotics,verysoftconsistencyforfeedingease throughtube if necessary.
2. Calculate Bosco’scurrent,estimatedenergyneeds(i.e.illnessenergyrequirement). Pleaseshowall
work. How are yougoingto get these caloriesintoBosco(i.e.how will yougethimtoconsume all of the
calories)?53 lbs/2.2 lbs/kg=24.1 kg , 1.0 x RER = 1.0 x [70(24.1 kg).75]=761 kcal per dayinitially
increasingthe multiplyingfactordependingonif weightlosshasoccurred,and/orhealthimprovement
continues.Iwouldfirstbeginby measuringthe propercaloricamountof foodnecessaryforthe entire
day andbreak thatamount upover4 - 6 feedings.Iwouldmeasure the total amountof foodfedfor
each meal before andaftertofirstsee if Bosco isconsumingthe correctamount.If notinterestedin
eatingI wouldtryto entice himintoeatingbyheatingthe food,handfeeding,ortryingto provide an
appetite stimulantsuchasdiazepam,etc.If that doesnotworkthenI wouldplace a feedingtube in
Bosco,such as a E tube or G tube to ensure the correctamountof caloriesisbeingconsumed.
3. Based onthe currentinformation,whatfood,fooddosage,andfeedingmethodwouldyou
recommendforBosco? How doesthisfoodcompare to the keynutritional factorsyoulistedinnumber
1? What wouldyoudoif he refusestoeat?I wouldtryto feedBoscoa recoveryformulasuchas Hill’s
Science DietA/D.Iwouldfeed4¼ cans per day,whichisequal to 763 kcal ,Iwouldadjustamount
accordinglyif weightlosshasoccurred,andas Bosco is becominghealthier. Iwouldbreakupthe
feedingsinto6feedings.The first5feedingswouldbe ¾of a can and the 6th feedingwouldbe ½of a
can. The latteris basedonlittle tono weightlossaswell asnohistoryof anorexiacausinganyGI
compromise.If there hasbeenanorexiathenIwouldadhere tothe followingschedule: 1/3 of the daily
caloricintake forday 1, 2/3 of the dailycaloricintake forday2, and the full dailycaloricintake forday3
and beyond.Thisfoodcontainsthe keynutritional factorsasI listedabove,exceptthatitdoesnot
provide probioticsandprebioticstohelpreplenishthe normal gutflorainthe patientthatiscurrentlyon
antibiotics.If BoscorefusestoeatthenIwouldmostlikelyplace afeedingtube suchasan E or G tube
until Boscois consistentlyeatingonhisownforsome time.
4. What parameterswill youmonitortodetermineisyouare feedingplanisadequate,insufficient,or
excessive? Howfrequentlywill youmonitorthese inthispatientandforhow long? What are your long-
termnutrition-relatedplans(next2-3months) forBosco (i.e.plansforwhenhe goeshome)? Please be
specificandthorough.Iwouldmonitorweighteverydayusingthe same scale andat the same time to
determine weightgainorlossandpreserve consistency.Iwouldalsomonitordailydefecationsto
ensure the dietisbeingtoleratedandthere are nosignsof diarrhea.Iwouldalsoperforma body
conditionscore onBosco every2 to 3 days to see if I notice anysignificantdeviationsfromthe ideal.I
wouldalsorunbloodglucose at leasttwice dailytoensure
that Bosco’sglucose levelsdonotdropbelow normal levelsbetweenfeedingintervals.Iwouldmonitor
all these levelsuntil Boscoisconsistentlyeatingonhisownorhas leftthe hospital.If Boscoisat home
and still beingfedbytube Iwouldhave toadjustwhatmonitoringIcoulddo accordingto the ownerand
availability.Once BoscoiseatingconsistentlyIwouldremove the tube if itwasnecessaryandstartto
transitionhimovertohisnewdiet.Iwouldrecommendtryingtograduallydecrease the amountof table
foodand rawhidesthatBoscowas receivinginthe pastbecause theyare a source of increasedcalories

3. and notnecessarilyof anysignificantnutritional benefit.If inthe pastBoscowas at an ideal body
conditionscore,andwashealthywhile beingfedAttaBoyDogfood,thenI see noneedto change that
food.I wouldfeedhimthe recommendedcaloricamountforan intactmale 53 lbs/2.2 lbs/kg=24.1 kg ,
1.8 x RER = 1.8 x [70(24.1 kg).75]=1,371 kcal per day.Thisis equivalentto4 ¼ to 4 ½ cups of Atta Boy
dog foodperday.I wouldbreakthe meal upintotwoseparate feedingsof 2 ¼ cups each.I wouldlike to
see Boscoback in twoweekstocheckhisweight andperforma bodyconditionscore.Iwouldadjustdiet
accordinglydependingonmyfindings.Once the infectionhassubsidedandBoscoisoff antibioticsI
wouldlike tostarthimon a course of prebiotics/probiotics(fortiflor,bene bac) tohelprestore normal
gut flora.Recheckradiographstoensure properfracture healing.Iwouldalsorecommendthatif Bosco
isnot goingto be a stud,the ownersmayconsidercastrationat a latertime,since thismayhelpprevent
roamingand decrease the riskof anothermotorvehicle encounter.(The latterisdependentonif the
accidentoccurredoff the propertyetc.) If the ownersdoelecttohave Bosco castratedthenthe amount
of foodbeingfedmustbe recalculatedforadog thatis no longerintactandalso depends onhiscurrent
activitylevel.
Case 2. Heidi Willis
Assessthe PatientHeidi,a7-yearold,spayedfemale,Dobermanpinscher,ispresentedtoyourclinicfor
herannual heartwormtest. She currentlyweighs60pounds. Heidi isan outdoordogwho is keptina
fencedbackyard or chainlinkkennel withinsulateddoghouse. She liveswithhercaregiver,Ms.Willis,
and 2 elderlycats. She iscurrenton all of her vaccinations. Yourphysical examinationrevealsalean
and alertDobermanwitha BCSof 2/5. The medical recordindicatesthatshe weighed69poundsand
had a BCS of 3/5 two yearsearlier.
Blooddrawnfor the heartwormtestrevealsayellow tinge tothe plasma. Beingconcerned,youdraw
more bloodand submititfora CBC andserumbiochemistryprofile. The dog’surinarybladderisbarely
palpable butyoumanage to obtain5 cc of urine viacystocentesisforaUA. On a secondand more
careful look,younotice thathermucousmembranesappearicteric. The onlyabnormalitynotedonthe
CBC resultsisa commentaboutoccasional targetcellsbeingseenonthe microscopicexaminationof the
bloodsmear. Abnormalitiesonthe serumbiochemical profile include albumin=1.9 g/dl (normal 2.5-3.8
g/dl);BUN = 8 mg/dl (normal 9-27 mg/dl);ALT= 301 IU (normal 21-67 IU); SAP= 362 IU (normal 14-72
IU); and total bilirubin=2.5 mg/dl (normal < 0.3 mg/dl). The urinalysisrevealsa3+ bilirubinuriawitha
specificgravityof 1.030 and a urine pH of 7.0. Additional workup:surveyabdominal radiography(small
liver) andliverbiopsy(hepaticdegenerationandnecrosiswithamixedinflammatoryresponse).
of copper/gof tissue). Yoususpectchronicactive
hepatitis.
Assessthe FoodandFeedingMethodHeidi hasbeenfree choice feddry,High-Prodogfood. However,
Ms. WillisindicatedthatHeidi’sappetite wasabit“off”because she wasnot refillingHeidi’sfoodbowl
as often.
High-ProDogFood Ingredientlist:Cookedyellow corn,meatandbone meal,cookedwheat,wheatbran,
corn glutenmeal,animal fat(preservedwithmixedtocopherols),brewer’srice,digestof poultry

4. byproductmeal,poultryby-productmeal,canolaoil,fishmeal,tomatomeal,mineralsandvitamins.
Guaranteedanalysis:27%protein;10% fat;4% fiber;12% moisture Nutritionstatement:Hi-Prois
formulatedtoprovide complete andbalancednutritionformaintenance.
GuidingQuestions1.Giventhisinformation,whatisyourinitial treatmentplan? Please be concise and
thorough.2. What are the keynutritional factors(KNF) andtheirappropriatelevelstoconsiderforthis
patient?3. What food,fooddosage andfeedingmethodwouldyourrecommendforHeidi (show all
work)? How doesthe foodcompare withthe keynutritional factors(i.e.compare eachfactor) youlisted
inquestion2? Whenand howwill youintroduce yourchosenfood?4.What are yourlong-termplans
for Heidi? Whatparameterswill youmonitortodetermine if yourtreatmentisadequate,insufficient,or
excessive? Howfrequentlywill youmonitorthese inthispatientandforhow long?
Case 2: Heidi Willis
1. Giventhisinformation,whatisyourinitial treatmentplan? Please be concise andthorough.If any
signsof dehydrationIwouldbeginwithfluidtherapytoreplace losesandtocorrect any electrolyte
imbalances.IwouldstartHeidi ona course of prednisolone(glucocorticoids) andantibiotics(depending
on culture or can use ampicillin,metronidazole,etc.) for1– 2 months.Alsostarton hepatoprotectants
(ursodiol),andpossiblysupplementwithVitaminCandZinc to decrease copperlevels.Bvitaminsand
digestive enzymesupplementationcanalsobe given.Provide supportforanyotherclinical signsthat
developsuchasvomiting,ascites,etc.Provide anew dietwithhighqualityrestrictedproteinandcertain
minerals.Recheckin2weekstodetermine weightgain,anddiettolerance.Recheckbloodlevelswhile
on steroids.Followupradiographsand/orultrasoundtodetermineascitesorprogressionof cirrhosis.
Additional liverbiopsyasneededdue tolongtermglucocorticoidtreatment.
2. What are the keynutritional factors(KNF) andtheirappropriate levelstoconsiderforthispatient?
The keynutritional factorsforthispatientare highqualityandhighlydigestible moderate amountsof
protein,normal amountof highlydigestible fat,normal amountof highlydigestible carbohydrates,
higherlevelsof fermentablefiber,normal toslightlyhigherlevelsof taurine,iron,zinc,potassium,L-
Carnitine,andvitamins,decreasedlevelsof sodiumchloride,andcopper.
3. What food,fooddosage and feedingmethodwouldyourecommendforHeidi (show all work)? How
doesthe foodcompare withthe keynutritional factors(i.e.compare eachfactor) youlistedinquestion
2? Whenand howwill youintroduce yourchosenfood?IwouldfeedHeidi Hill’sScience DietL/DCanine
HepaticHealth.IwouldfeedHeidi forweight gaintobringherback to an ideal body
conditionscore,butstartingoutat a lowermultipliersince she mighthave beenanorexic.If there has
beenanorexiathenIwouldadhere tothe followingschedule: 1/3of the dailycaloricintake forday1,
2/3 of the dailycaloricintake forday2, and the full dailycaloricintake forday3 and beyond.69 lbs/2.2
lbs/kg=31.4 kg , 1.2 x RER = 1.2 x [70(31.4 kg).75]= 1,113 kcal per day.I wouldfeed2¾ cupsto 3 cups
perday, 1 ½ cupstwice dailyequal to1,197 kcal per day.The keynutritional factorsmatchup well
concerningprotein,carbohydrates,fat,fiber,L- Carnitine,copper,iron,zinc,potassium, andsodium, I
couldnot findinformationaboutthe varioustypesof vitamins,andtaurine andthere levels includedin
the diet.I wouldintroduce the foodtoHeidi athome ratherthan the clinicsothat she wouldnotbe
adverse toit.I wouldslowlyswitchherovertothe new foodovera weeklongperiodasfollows:day1=

5. 90% old,10% new;day 2= 75% old,25% new;day3= 60% old,40% new;day 4= 50% old,50% new;day
5= 40% old,60% new;day 6= 25% old,75% new;day7= 10% old,90% new;day8= 100% new diet.
4. What are your long-termplansforHeidi? Whatparameterswillyoumonitortodetermineif your
treatmentisadequate,insufficient,orexcessive? How frequentlywillyoumonitorthese inthispatient
and forhow long?I wouldstartHeidi ona course of prednisolone (glucocorticoids) andantibiotics
(dependingonculture orcan use ampicillin,metronidazole,etc.) for1 – 2 months.Alsostarton
hepatoprotectants(ursodiol),andpossiblysupplementwithVitaminC,E and Zincto decrease copper
levels.Bvitaminsanddigestiveenzyme supplementationcanalsobe given.Provide supportforany
otherclinical signsthatdevelopsuchasvomiting,ascites,etc.Recheckin2weekstodetermine weight
gain,and diettolerance.Reweighandassessdiet,recheckagainevery2weeksuntil weightlevel is
appropriate thenadjustcaloricintake formaintenance.Recheckbloodlevels(Albumin,AST,ALP,total
Bilirubin,BUN,CBC,WBC,copper,sodium, potassium,etc.) while onsteroidsforlongterm.Followup
radiographs and/orultrasoundina couple of monthstodetermine ascitesorprogressionof cirrhosis.
Additional liverbiopsyasneededdue tolongtermglucocorticoidtreatment.Iwouldmonitorweight,
BCS, bloodlevels,andradiographs.Once Heidiisata good weightshe canbe monitoredforweight
stabilityevery4to6 months,andbloodlevelsatleasttwice yearly,andradiographs/ultrasoundatleast
yearly.