C09971542 / invoice 10000

Reason: Not Eating, Lethargic Appointment Notes: Overdue reminders**Owner is a GP**History: - Presents for acting abnormally at home- Today she seemed very weak, O describes her as being "floppy"- Also not wanting to eat much today - O did offer her some food in bed and she are a small amount- Held insulin when not eating, has administered after she has eaten - Is on 1IU SID in the morning - Has a number of comorbidities: IMHA, significant atrophy of the R kidney, hydronephrosis of the L kidney, diabetes - Diabetes has been recently difficult to control, has periods of being very hypoglycemic, glucose seems to spike and dosing has been difficult re Insulin - Historically has been on prednisolone for IMHA- Recently, has been started on Atopica in order to try and wean prednisolone to help with diabetes control - Upon weaning prednisolone recently,her PCV dropped from 30 to 21 - Is on 0.3ml ciclosporin (ATOPICA FOR CATS) BID, and prednisolone 3/4 of a 5mg tablet BID (weaned down to 1/2 and this correlated with a drop in PCV from 30 to 21) - Was brought in on early this week for bloods as had vomited once and seemed to be flat over the weekend and had done some inappropriate urinations in the house- Fructosamine normal, NSAID profile normal, urine unremarkable on the 25/02/26 - Urine was unremarkable - Main concern today is that she was very floppy, not wanting to eat anything - O concerned about dropping PCV - Had an ultrasound in December - Results summarised:  1. Pancreas mildly to moderately enlarged in size, with hypoechoic, coarse echotexture parenchyma. DDx possible chronic inflammatory change2. Liver increased in echogenicity. DDx vacuolar vs fatty vs inflammatory hepatopathy.3. Small/shrunken right kidney. DDx previous insult, with subsequent atrophy & likely reduced function.4. Hyperechoic structure in a left renal diverticulum. DDx non-obstructing nephrolithExamine- Weight 5.5kg, dropped from 5.9kg in December, O has been concious of what she has been eating as historically overweight but has never previously been successful in getting her to lose weight- MM Pale pink CRT<2 - HR reg no murmur, thoracic auscultation WNL- Normothermic 39- Query firm mass, craniodorsal mid abdomen, unsure if this is a firm kidney vs other mass, reactive to palpation- Thickened bladderBloods:- PCV 18 TP 78- Mild lyphocytopenia 0.91, eosinopenia 0.03, - Hyperglycemia 18.76- Fructosamine H 375 - TT4 WNL 26- CRP WNL - QPL H 24.7UA: - Unremarkable, hematuria but collected via cystocentesis and she wriggled so likely iatrogenic POCUS: - Bladder wall appears thickened at the dorsal aspect, hyperechoic flecks/query sediment in bladder- Subjectively large liver- Query mass caudal to the liver, cranial left abdomen, region of the pancreas vs distended stomach with very poor peristalsis?? - No FAF- L kidney v small, R kidney appears to be hydronephrotic  Radiographs: - Query mass effect in the cranial left abdomen, with displacement of the small intestines to the right - Query soft tissue structure caudal to the liverProblem list1. Lethargy and inappetence2. Worsening HCT (30 -> 21 -> 18) despite increasing pred dose, non regenerative anemia, and lack of hemolytic change on bloodwork not supportive of IMHA - ie no hyperalbuminema, no inflammatory changes. No pyrexia on exam. Reluctant to keep increasing pred dose if anemia is not IMHA, other ddx anemia of chronic disease, chronic blood loss etc 3. Uncontrolled diabetes4. Pancreatitis (acute vs chronic?)5. Abdominal pain 6. Query mass in the abdomen 7. Renal changes  Assessment: - Multiple co-morbidities making management complex- Cannot rule out abdominal mass, needs further imaging - O is really keen to do everything for Lottie- Referral to SASH internal medicine for second opinion and likely advanced imaging- Given dropping PCV, going through ECC - ZP call to do handoverEstimate - 6-10k for CT etc    Vital Signs    Weight: 5.5 ;