C09980713 / invoice 10000

03/03/2026 History:
- Vomiting approximately 6 times since 1am.
- No longer bringing anything up.
- Anorexia, refused breakfast.
- Not prone to vomiting, previous episodes were only once or twice.
- No history of eating unusual items.
- No known dietary changes.
- Last bowel movement was 2 days ago, normal appearance.
- No diarrhoea observed.
- Reduced water intake, only 1-2 laps only .
- Fast panting while lying down this morning.

Past Medical History:
- Generalised muscle atrophy, possible polymyositis.
- Bilateral otitis externa (yeast) on 23/06/2025.
- Urinary tract infection on 24/05/2025.
- Medications: 
-Gabapentin 100mg twice daily for pain management.
- Prednisolone 5mg, three tablets once daily in the morning. Was started mid 2025 as presented with lethargy/pyrexia that progressed to collapse in rear and inability to open mouth-responsive to prednisolone 

Physical Examination:
- Gums: pink, slightly tacky.
- Abdomen: uncomfortable, cranial abdo palpation starts to pant heavily .
- Temperature: 39.2°C.
-Generalized muscle weakness in rear-very skinny legs and urine staining on coat over legs 

Impression & Plan:
1. Vomiting and Anorexia
- Impression: Dehydration, abdominal pain.
- Investigations planned: Abdominal ultrasound.
- Treatment planned: Pain relief . IV fluids, anti-nausea medication, and pain relief to be considered -EOC 1200-1500-O elects pending ultrasound results.
- Clinician's recommendations and counselling: Discussed plan with owner, including costs. Owner consented to proceed with ultrasound but declined anything further re costs  Will call owner with results and further plan.

Next Steps
- Await results of the abdominal ultrasound.
- Owner will be contacted with the results and the next steps in the treatment plan.

+++Abdo Ultrasound Dr Mei+++++
Sedated iv 






MIR 3.30pm  -called and spoke to Jon -advised that we ideally need iv fluids as concerned re renal changes and current dehydration ,also debri in bladder may have UTI ongoing -need to rule out .
Advised No obvious blockage. Stomach is inflamed and gas-filled with increased motility. Chronic renal and liver changes noted, likely related to ongoing cortisone use. Some debris in urine. Dehydrated. 

OK to go ahead -plan to give maropitant iv +paracetomol and rehydrate  then home at 5.40pm and iv in overnight-poss readmit in am .++++++++++++


+++++++++++++LMG from here +++++++++++++

Laboratory:  Urinalysis in house - dipstick

Collection method: voided  
Urobilinogen: normal 
Protein: Trace 
pH: 7
Blood: -
Ketone: -
Bilirubin: - 
Glucose: - 
USG: 1.010
Sediments: 
Wet - 
Dry -  rods+++++

TREATMENT:
Hartmanns 5ml/kg bolus then 1.5x maintence 
cephazolin 22mg/kg slow IV. Home on amoxyclav and paracetamol. 

Client comms:
STO and discussed concern over pyelopnephritis esp given fever and massive rod infection in urine
Rec bloods. 
O Ok with this 

CBC:
Borderline low hct 
Elevated WBC 21.7 (RR 5-16.76) 
Elevated neutrophils 18.9 ( RR 2.95 - 11.64 x10^9/L) 
Machine reading low platelets but significant clumping on smear
 
Biochem: 

Creatinine low 29 (RR 44-159 umol/L) 
ALT elevated 471 (RR 10-125) 
ALP elevated 1224 (23-212) 

ASSESSMENT:
Ok for dc tonight on oral ab - recheck in am
If not well will admit for IVFT during day. 

TREATMENT:
Home on paracetamol 15mg/kg PO BID
Clavulox 15mg/kg PO BID 10d

PLAN: 
recheck in am incl temp check -if well pull IV. 
Would like Luna to have a consutl with Dr Amy for review in 10 days to recheck UA and follow up with myostitis. 


03/03/2026 Abdominal Ultrasound: Dr Mei Russell
Equipment: Versana Active
Reason for U/s scan: Vomiting.
Sedation: Butorphanol 0.35 mls slow IV insufficient/ medetomidine 0.05 mls IV. Reversed with atipamezole 0.05mls

FINDINGS:

No free peritoneal effusion observed. AFS score 0/4.

Kidneys - Both kidneys are of normal shape with smooth contour and normal cortical echotexture. The central echogenic complexes have a normal appearance with no hydronephrosis. The right kidney measures 6.57 cm and the left kidney measures 5.45 cm. Mild loss of CMJ in both kidneys.

Spleen - normal size, shape and isoechoic to the liver.

Bladder - Moderately distended with a small amount of sediment present. The bladder wall is 1.6 mm thick with no loss of lining, layering or differentiation. Trigone is clear.

Liver - Sharply marginated. Generally hyperechoic and coarse in echotexture. Isoechoic with the spleen. Extends past CC junction.

Gallbladder - The gallbladder wall measures 2.57 mm. Dependent sludge and small amounts of sediment present.

Mirror artifact observed with no free pleural effusion observed.

Gastrointestinal - Stomach is full of gas. Stomach lining (fundus) measures 5.73 mm. The pylorus measures 8.05 mm. Increased fluid and peristalsis present in the small intestines. Jejunum measures 2.25 mm. No obstructive pattern observed.

Pancreas - NAD

LNs – Medial iliac lymph nodes are normal.

Adrenal glands - The left adrenal gland measures 6.53 mm and the right adrenal gland measures 3.09 mm. Both are generally homogenous in echogenicity and echotexture.

ASSESSMENT:
1. Vacuolar hepatopathy - DDx include steroid hepatopathy (secondary to prednisolone) or cholangiohepatitis.
2. Gastritis and enteritis.
3. sediment in bladder - DDX: UTI, crystalluria, pyuria, Normal for this patient.

PLAN:
- Recommending IVFT due to vomiting and kidney changes.
- Consider further diagnostics for hepatopathy.