C09975739 / invoice 10000

Presenting Complaint:
Recheck autoimmune inflammatory condition and steroid dose reduction.

Hx: BIB Dianne and Chris
Recurrent autoimmune inflammatory SRMA type condition
Currently weaning off prednisolone.
Was stable on 1.25mg pred twice a week previously.
Last relapse in December 2025, CRP was 212. Responded well to steroids immediately.
Currently on prednisolone 5mg, one tablet every second day - been on this for past 4 weeks. 
Has gained weight since December (6.4kg to 7.3kg).
Owner reports full of life, running around, good energy levels.
no c/s/d/v
eddu all ok

Diet:
Delicate Care dental hard food.
Chicken or tuna meat with rice, peas, and carrots.

Medication:
Prednisolone 5mg tablet every second day.

Parasite and Vaccination Preventive:
Nexgard Spectra, up to date. Next due 01/04/2026.

PEx:
Temperament: BAR, A little nervous but friendly.
BCS: 6/9
MM: pink and moist, CRT: 1-2 sec
Mouth: Grade 1/4 dental disease. Mild tartar build up, worse on left maxillary premolars/molars. Chews more on the right side.
eyes: NAD
ears: NAD
nose: NAD
Cardiovascular: HR: 140 bpm, PR: Murmur: No
Respiratory: RR = 50, lung sounds are normal.
Lymph nodes: NAD
Abdominal Palpation: Soft, non-painful.
Skin/Coat: NAD
Musculoskeletal: NAD
Genitalia: NAD
Rectal temperature: 38.5 C

Laboratory results:
Blood test on Christmas Eve (24/12/2025) was normal, prior to starting steroids for recent flare.
No new blood tests performed today.

Assessment:
Autoimmune inflammatory condition - currently in remission on prednisolone.
Mild dental disease (Grade 1/4).
Weight gain - likely secondary to steroid use.
Plan to continue weaning prednisolone based on clinical signs.
Long-term side effects of steroids discussed with owner (muscle wastage, skin thinning, infections, impaired vaccine response, medication interactions, iatrogenic Cushing's disease, diabetes, pancreatitis).
Benefits of low dose steroid therapy (quality of life) outweigh risks at this stage.

Plan:
Reduce Prednisolone to 2.5mg (1/2 tablet) every second day for one month.
Recheck teeth in 6 months for complimentary dental check.
Continue dental diet.
Advised on risks/benefits of feeding bones for dental health.
Monitor weight.
Advised to call for a recheck in one month or if any concerns.

Consult Summary:
Recheck for autoimmune condition.
Indie is clinically well.
Physical exam unremarkable apart from mild dental tartar and weight gain.
Plan is to continue weaning prednisolone dose.
Reduce to 2.5mg every second day for one month.
Recheck teeth in 6 months.

Called to check in how Indi was going after ceasing gaba and reducing pred dose - O says playful and going on short walks -0 still slightly more sleepy than normal but otherwise going well EDDU BAR MC

Phone Communication Note - 
Date of Call: 27/12/2025
Time of Call: 9:48 AM
Communication: Outgoing call to Diane.
Regarding: Indie Cook - Follow-up on inflammatory condition.

Owner's Report:
The owner reports that Indie is "almost normal" and is very responsive to the steroid medication. Her temperature this morning was 38.3°C, which is a decrease from 39°C yesterday. The owner has been monitoring her temperature daily. Indie is currently on 5mg of prednisolone twice daily, but the owner has planned to reduce this to once daily due to her significant improvement. The owner reports that Indie is "so good" and feels "so normal now".
Has also been giving half a 100mg gabapentin and will cease that today given improvement in pain. Only occasionally looks a little hunched but is eating and running around normally.

Assessment/Advice:
Blood test results from this morning were reviewed. The red and white blood cell counts and organ function tests were all within normal limits. However, the C-reactive protein (CRP) level was significantly elevated at 212 (normal <10), confirming an active inflammatory process, similar to previous episodes. The current presentation is consistent with a relapse of an underlying autoimmune inflammatory condition. The trigger for this relapse is unknown, which is typical for these conditions. The plan is to find the lowest effective dose of steroid to maintain remission, as it is likely Indie will have recurrent episodes throughout her life. Given her excellent response to the steroid and current clinical normalcy, it is appropriate to reduce the medication load.

Plan:
- Reduce prednisolone to 5mg once daily for 4 weeks then review dose.
- Cease gabapentin, as it is for pain relief and she is no longer in pain.
- A nurse will call the owner on Monday, 30/12/2025, to check in on Indie's progress.