C09979902 / invoice 10000

03/03/2026 
NURSE: KR

REASON:
Originally booked for repeat Beransa and bloods but Samson has become unwell again.

HISTORY:
- Intermittently inappetent past week. Not eating full meals. Eating small amounts and snacks but will turn nose away quickly 
- 1kg weight loss in 1m 
- No V or D.
- Was hiding tablets in food - O unsure if this contributed to being off food. O changed to tableting orally.
- Very flat and low energy. Usually stressed in clinic but laying on floor.
- Similar to last episode of these symptoms, but probably worse this time? 

CURRENT MEDICATIONS: 
Denamarin x2 425mg SID. 
Pregabalin 75mg BID. 
Metacam SID - not eating (O usually dribbles on food)
**Hasn't been getting medication consistently due to inappetance and difficultly to tablet 

CLINICIAL EXAM:
- Mentation: QAR - flat
- MM: pink
- CRT: 2s
- Oral and Dental Score: 
- Eyes: Possibly slight yellowing of sclera 
- Ears: Not assessed
- BCS: 4/5
- Lumps: Not assessed
- Abdominal: Possibly discomfort in cranial 
- Lymph nodes: Not assessed
- HR: 120bpm
- RR: Not assessed
- Temp: 39.8°C 
- MSK: Not assessed

ASSESSMENT:
Pyrexia - nonspecific 
Previous elevated liver values - need to repeat bloods. Could be related to liver or something different 

DISCUSSION:
- Discussed pyrexia can occur with nonspecific inflammation, infection, cancer
- Discussed liver issues - can have infection in liver or gallbladder causing elevated liver values and temperature
- Recommend repeating full bloods, UA +/- abdominal U/S today 


PLAN:
Admit for full bloods, UA, likely abdo U/S

__________________________________________________________________________________________________

FULL BLOODS:
Difficult to perform blood collection; attempted jugular, R cephallic vein and L saphenous vein. Managed to collect enough for UFO to run Clip 17:

CLIP 17:
Globulin 48 (25 - 45 g/L)
ALT 914 (10 - 125 U/L)
ALP 1,000 (23 - 212 U/L)
Bilirubin - Total 18 (0 - 15 µmol/L) 

UA:
Collection Free Catch
Colour: Dark Yellow
Clarity: Cloudy
Specific Gravity 1.038
pH 8.0
Urine Protein 1+ mg/dL
Glucose neg
Ketones neg
Blood / neg
Haemoglobin
Bilirubin 1+ mg/dL
Urobilinogen 3+ mg/dL
Leukocyte 1+


BLOOD PRESSURE READINGS (R FORE; SIZE 8? CUFF)
138/106 (117)
119/48 (71)
156/92 (113)
134/101 (116)
158/57 (102)
140/79 (115)
155/76 (102)