C09979815 / invoice 10000

Discussed starting Cushings treatment with O:
1. O prefers liquid formulation, very difficult to tablet - Trilostane compounded liquid 1mg/kg 15mg/ml 1.5ml PO BID. Store in fridge and shake well before use
2. Cortate 25mg to have on hand, to be given in case of addisonian crisis. 
3. 2 weeks from start date of Trilostane to repeat ACTH stim. ACTH stim required 2 weeks post any dose adjustments
Will order medications and text O when ready for pick up

Email to o:

Hello Raymond,

Please find attached, Ollie's ACTH stimulation test results with this email. 
His cortisol post ACTH is very high, which is suggestive of Cushings disease or hyperadrenocorticism.
The test results combined with his clinical signs of excess thirst, urination and hunger are more likely suggestive of cushings disease.

Cushings disease results when there is an excess production of cortisol in the body. This could be caused due to a benign tumour either in the brain or in adrenal gland.
Treatment involves starting Ollie on a medication called Trilostane, which will help control his symptoms. 
We obtain trilostane from compounding pharmacies and it needs to be given on a daily basis. Ollie's bloods can be tested 2-4 weeks after starting this medication and his dose may need to be regulated based on his response. 

More information about Cushings disease and Trilostane can be found in these links:

https://veterinarypartner.vin.com/default.aspx?pid=19239&id=4951983

https://veterinarypartner.vin.com/default.aspx?pid=19239&id=4951510

https://veterinarypartner.vin.com/default.aspx?pid=19239&id=4951512


Please don't hesitate to contact us if you have any queries or wish to discuss further. Also once you're back in Sydney we recommend that you come in for a recheck to discuss all the diagnostic and treatment options in more detail.


Kind regards
Dr Gowri Menon

Reason: ACTH stim (external).

History:
Urinating randomly - O takes him out every morning and will urinate for 30s and sometimes up to 1 minute. Drinks alot of water, throughout the day just lays around. 
At night is drinking constantly. O fills 2L bowl and its almost gone in the morning (willow shares this bowl but O feels Ollie does majority of the drinking).
At afternoon walks also urinates. Over the past 2 weeks he will randomly hops up onto the bed and urinates (always 1 specific bed). Other times he will walk around the lounge and just suddenly urinate. At least 1L worth, large volume. No blood in urine, normal colour, no potent smell. 
Something that is worsening seems to be his reaction to noise. Fireworks during christmas and NYE has always been disturbing to him, but nowadays even a drop of a shoe or fork he will be startled, other dogs barking annoys him too. Seems to be on edge. Sometimes will stare at balcony and bark 
Sleeps and eats well, defecation is normal; firm healthy stools of normal colour (beige to dark brown)
Diet wise - grazes all day, male O feels he is fed too much. Gets a bit of steak and veggies if O is eating this, gets raw kangaroo bones, loves watermelon; dry kibble, dried chicken fillet treats. 

In house ACTH stim inconclusive at last visit - here for send off ACTH stim.

Treatment:
Catheter placed R cephalic, 1ml blood obtained from catheter "time 0"
Synacthen 0.45ml iv @ 10:17
"time 1" 1 ml blood collected from catheter 11:17.

Assessment/Problem List:
1. PUPD
2. Noise sensitivity
DDx: Suspected cushings vs. renal; noise sensitivity possibly attributed to anxiety vs. cognitive decline?

Plan:
Awaiting ACTH stim results. If also inconclusive to consider LDDST +/- urinalysis. 
Discussed sileo gel for noise phobia - O can trial prior to storm/concerts in olympic park/fireworks. 

Cost zeroed due to error on our machine last week.