C09972073 / invoice 10000

02/03/2026 Clinician: BMV

History: 
Presented for revisit today. Diagnosed with IMHA 18th October @ AES. 
Had her on 5mg prednisolone SID for 1 week, then 2.5mg PO SID for 1 week then stopped. 
Because she had sores on the back of her leg and her dew claw wound wasn't healing. These have since healed. Gained weight. Urinary incontinence has resolved. Urine normal colour. Pelvic limb weakness has resolved. EDDU normally. Bright and energetic. 

Meds:
- prednisolone owner discontinued
- rivaroxaban owner discontinued

Exam:
BAR, BCS 4/9, HR 104, RR 24, T 38.3
MM: pink and moist, CRT < 2 sec
EENT: eyes clear, no discharge, no blepharospasm. Ears clean, no discharge, no malodour. No nasal discharge. 
CV/Resp: heart auscults clear, no murmurs noted. Clear breath sounds in all lung fields, no crackles or wheezes
GI/UG: abdomen soft and non-painful, liver does not extend beyond the costal arch. 
Integ: clean and shiny haircoat
LN: peripheral lymph nodes palpable < 1cm

Diagnostics:
1) PCV/TP 54/65, serum clear
2) Smear
3) FBE pending Aurora

Assessment: 
- Non-associated IMHA
- Chronic intermittent cough - worse when first gets up from rest, sometimes excitement/pulling lead. Thoracic radiographs October revealed mild bronchial pattern caudal lung field, cardiomegaly (however sedation is considered as possible factor). Further investigation would entail CT +/- bronchoscopy +/- BAL
- Recent CRP elevation - resolved today.
- Pelvic limb weakness - suspect prednisolone induced vs pathological

Plan: 
- To contact owner with FBE result once returned. 
- If in remission, recommended reassessing FBE in 4 weeks, sooner if any concerns.