C09978786 / invoice 10000

HISTORY: Libre fell off after one day
- AVC said control was not good which is why they change 
- been normal, not drinking excessively 
- giving 6iu BID 

EXAM:
BG 8.2 mmol

PLAN:
Applied new libre 

COMMUNICATION:
Rebook recheck in 1 week
Told not to look too closely at numbers - that is the vets role. Adv to look at how she is looking clincially: appetite, drinking, activity 

SUBJECTIVE: diabetic review 
current investigations at Advanced Vetcare Kew for anal sac neoplasm -has been changed to **Toujeo in the past 3 days **
Toujeo insulin 6 IU SID

PROBLEM LIST:
* Uncontrolled DM with PU/PD, weight loss, hyperglycaemia, glucosuria and ketonaemia.
* Ketosis - previous DKA in Nov 2024, poss UTI at that time (no culture, cocci seen on
sediment exam in-house, no pyuria)
* Chronic patchy alopecia (for years) - possible underlying endocrinopathy (hypoT,
hyperadrenocorticism) vs primary dermatological condition - TT4 mildly low on 13/1/26 (13)
but improved from 9 in July 2025 when cTSH was normal at 0.12 ng/mL (RR 0.10 - 0.45). No
anaemia, hyperlipidaemia, bradycardia or weight gain to support a diagnosis of
hypothyroidism, so likely sick euthyroid syndrome.
* Haematochezia - Ddx pancreatitis, colitis (inflammatory, stress), polyp, anal sac
adenocarcinoma (less likely cause) -  resolved 
* Heart murmur, subclinical - likely MMVD - yet to be staged
* Mild elevation in ALP (normal July 2025) - Ddx diabetes, pancreatitis, biliary mucocele,
primary hepatopathy, endocrinopathy
* Untreated anal sac adenocarcinoma, normal iCa, yet to be staged

OBJECTIVE:
BAR, mm pink and moist, CRT<2
eyes - pupils clear 
ears NAD
HR 120, G3-4 murmur 
RR 32
abdo - NAD
anal gland mass 
hair coat that dose not grow back 


ASSESSMENT:
o.s have transitioned to toujeo 300IU in the past 3 days  
started cardisure at AVC 

PLAN:
need to monitor BG closely with new freestyle libre placed today
monitor thirst and eating 
had been steady with previous insulin  but some ups and downs 
all readings high at present 
COMMUNICATION:

SUBJECTIVE:
O concerned as today has had a couple of episodes of collapse - legs went out from under pt. 

Long Hx of diabetes, also of signficant heart murmur, also of AG carcinoma. 
Has been seeing AVC for AG issues, they have recc consult with IM -has appt with IM next week

Previously had DKA episode around Christmas 2024, but none after that. For last 12 mo (approx) insulin dose has been 8iU BID, O had independently increased dose to 10iU. Onco recommended increasing dose further 2 weeks ago when noted BG was high at time of blood test (O was giving 10iU at time of test).

Today, given Insulin @7am 12iU

No V+D+, appetite low, energy low

Occasional soft stool over last several days but this is not unusual for this pt


OBJECTIVE:
BAR in consult
mm pink, moist, CRT <2
Generalised severe periodontal dz 
HR 124 RR 20 T 38.3
loud 5/6 palpable cardiac murmur PMI left apex, pulses good and synchronous
Lung fields clear bilaterally
Abdominal palpation WNL
Rectal exam not performed
Full ortho exam not performed
No obvious neuro deficits

Spot checks; 
KET = 0.2mmol
GLUC = 3.3mmol


ASSESSMENT:
Loud cardiac murmur
Known AGASACA
Diabetes mellitus - NOT ketotic, hypoglycaemic
Soft stool


PLAN:
Gave meal of a/d, ate very well
Placed CGM
Consider admission for monitoring +_ chest rads

CLIENT COMMUNICATION:
Long disc with O Greg RE: current concerns
Collapse episodes may be related to hypo episode vs cardiac insufficiency and syncope
O hesitant to work up today - disc that reasonable to consider monitoring at home if CGM is in place, esp as has eaten a/d well
O understands that will need to keep tabs on BG by using CGM - aware that if lower than 5 needs to call clinic, if lower than 3 needs to urgently bring to clinic 
O declined admission for monitoring/further testing
Directed O to give full meal when gets home, then check BG 30 min after meal. If 10 or above, then give 3iU. If lower than 10, do NOT give insulin. 
Re-start insulin dose tomorrow at 10iU 
O has appt with AVC IM dept next week