C09972204 / invoice 10000

Problem List:1) Chronic Hepatopathy> hepatomegaly with poorly contrast enhancing nodules on CT> chronic ALT and ALP elevation on blood tests> severe copper accumulation on biopsy (>1600ppm), centrilobular and midzonal accumulation (score 4)> mild lymphocytic inflammation on histopathology with moderate fibrosis progressing to cirrhosis score 4/4 on WSAVA grading) - most consistent with reactive inflammation2) Acute vomiting (December)3) Ventrocaudal abdomen cutaneous plaque lesions4) Grade I/VI left systolic murmur5) conjunctivitis (allergic, mild)Multiple cutaneous skin nodules (small, benign aetiology preferenced)Solitary 6mm lung nodule on CT2 small pulmonary bullaeRecent History:Stanley commenced chelation therapy for a copper associated hepatitis at the beginning of February. He has recovered well from his laparoscopic liver biopsies and had minimal adverse effects to once daily penicillamine but developed haemorrhagic diarrhoea on when increased to twice daily dosing (after one day) Owner reported intermittent episodes of abnormal breathing - possibly reverse sneezing. Appetite - excellent. Diet - feed predominantly heptic wet and dry. Faeces - melena when given D-penicillamine twice daily one week ago. Vomiting - will vomit if given 250mg D-penicillamine. Only vomited when given the higher dose, otherwise wont vomit Resp - no coughing, sneezing or nasal dischargeHad episode of suspected URT obstruction (? Reverse sneezing) was very distressed but lasted about 30-60 seconds. Then returned to normal and no further respiratory signs. Thirst - no change, still increasedUrination - always polyuric according to owners no pollakiuria or stranguria. Mobility - no lameness or mobility issues, occasionally stiff in mornings but normal for himBehaviour - normal energyRecent Diagnostics:Imaging: Laboratory:16/01 RBCC 6.5, Hct 0.39, MCV 60 L, MCHC 344, retic 64, retic-Hgb 21.1 L, WBCC6.2, neut 3.9, mono 0.5, lymph 1.7, plt 280Chem - TP 68, alb 33, glob 35, Glu 5.2, K 4.8, tCa 2.6, Phos 1.2, Tbili 3, ALT 299, ALP4182, AST 56, chol 6.7, TG 1.88 HCoagulation - PT 8.9 (7.2-11), aPTT 10.3 (10.4-16) WNL19/12 VetnosticsHct 0.40, MCV 59 L, MCHC 338, retic 0.08, retic Hgb 19.9 L, neut 3.6, band 0, mono0.4, lymph 1.3, plt 260TP 74 (H); alb 35 (27-38) Glob 39 (H), lytes wnl, tCa 2.6, Phos 1.2, urea 3.9, creat 72,Tbili 2, ALT 409 (H), AST 69, ALP 5746 (H), chol 8.7, TG 0.8TT4 24cPLi (in-house) - WNLCurrent Medications:D-penicillamine 125mg (half dose ~9.5mg/kg) q12hExamination:HR:  RR:  MM: pink/moist  CRT <2s  Temp:  COral: no dental disease, no pain on opening mouth, no visible lesionsEars: no discharge, no erythemaEyes: no discharge no conjunctival/scleral hyperaemia, fundic exam not performedNasal: no discharge, no pain on palpation of sinuses, no evidence of deformityCVS: no murmur, normal rhythm, strong synchronous pulsesResp: normal effort, normal bronchovesicular sounds all quadrantsAbdomen: no pain on deep palpation, no palpable fluid wave, no masses palpableGenitourinary: Rectal: normal formed faeces, anal sacs palpate normally, no palpable irregularities to mucosaMSK: normal ROM, no pain on palpation, no palpable joint effusionsNeuro: appropriate mentation, normal gait and posture, no spinal pain. Brief CN exam WNLPeripheral LNs: submandibular, prescapular and popliteal nodes are symmetrical and smallIntegument: coat is in good condition, no palpable or visible lesions to skinBCS:   /9Weight:    kg Laboratory:Problem List:Assessment:Treatment:Plan:Communication:Client - Vet -    Vital Signs    Weight: 25.7;       

Reason: O Called To Advised They Decreased Medication DosaAppointment Notes: as was having black stool. Please call daughter 0410605214 AmyHad an episode of difficulty breathing - resolved spontaneously seemed to be having difficulty breathing in and was noisy. Checked gums and was ok. Now is back to breathing normallySounds like reverse sneezing so advied owner to watch youtube videos of this to see if matches - and to film episode if happens again.Faeces have returned to normal. Did just increase chelation to twice daily for only one day and developed worsening diarrhoea so dropped back to once daily.    Vital Signs    

History: Laparoscopic liver biopsies 2 weeks ago.  Has started liver medications 4 days ago.  Has vomited twice and had some diarrhoea since then.  Has been in contact with dr Ciaravolo regarding this.  Otherwise doing well.Examination: BAR. Wounds have healed well.Assessment: Woinds healed.Plan: Sutures removed.  Continue contact with Dr Ciaravolo regarding liver disease treatment.    Vital Signs