C09984978 / invoice 10000

Temperatuire 40.38


Presenting Complaint: Recheck for pyrexia and lethargy.

Hx:
Minor improvement in demeanor, but generally the same as last visit.
Owner reports some diarrhoea. No vomiting reported.
Appetite is poor. Eating small amounts of raw meat but refusing chicken.
Drinking water well.
Weight loss of 500 grams, current weight 25.1kg.
No known toxin exposure, owner is aware of snails in the yard.

Diet: Small amounts of raw meat.
Medication: Ondansetron.
Parasite and Vaccination Preventive: not discussed

PEx:
Temperament: Quiet.
BCS:
MM: pink and moist, CRT: 1-2 sec
Mouth: NAD
eyes: NAD
ears: NAD
nose: NAD
Cardiovascular: HR: Murmur: No
Respiratory: lung sounds are normal
Lymph nodes: NAD
Abdominal Palpation: NAD
Skin/Coat: NAD
Musculoskeletal: NAD
Genitalia: NAD
Rectal temperature: 40.3
Other Issues:

Laboratory results: In-house test for leptospirosis was negative.

Assessment:
Persistent pyrexia (fever of unknown origin).
Diarrhoea.
Inappetence and weight loss.
Condition is largely unchanged since last visit. Concern for ongoing infection or inflammation. Plan is to add a broader spectrum antibiotic and symptomatic treatment for diarrhoea, with further diagnostics if no improvement.

Plan:
Enrofloxacin 150 mg: 1 tablet once daily for 2 weeks.
Amoxicillin and metronidazole continued as previously prescribed.
Pro-Kolin paste: 5 mL by mouth, morning and night, until stool is formed.
Hepato-Advanced (Denamarin) to be ordered to support liver function.
Owner to collect more Amoxiclav on Friday.
Advised to monitor for any worsening of signs.
Recheck booked for Friday 06/03/2026.
Plan to run a repeat non-interpretive blood profile on Friday.
Abdominal ultrasound may be performed on Friday to assess liver and biliary structures, similar to previous investigations.
Referral may be considered if she deteriorates or fails to respond to treatment.

Consult Summary:
Recheck for ongoing pyrexia, lethargy and diarrhoea.
Temperature remains elevated at 40.3C.
Has lost 500g.
Added Enrofloxacin and Pro-Kolin to treatment plan.
Recheck with blood tests scheduled for Friday.
Discussed potential for ultrasound and referral if no improvement.

Urinalysis results:
- USG: 1.011
- Pro 2+
- Pro/Crea: >0.5<2
-pH 6

I could not see anything on the dry prep. 
Imagyst not run? 

Phone Communication Note - JC
Date of Call: 03/03/2026
Time of Call: 5:32 PM
Communication: Outgoing call to Tracy.
Regarding: Xena - Blood test results follow-up.

Owner's Report:
Watery, pasty diarrhoea. Eating a little bit but appetite still not there.

Assessment/Advice:
Blood results not as concerning as previous hepatitis episode in 2023. White blood cells and red blood cells normal. Slight low glucose, likely sampling error. Bilirubin mildly elevated at 7 (normal less than 6), compared to 15 during hepatitis episode. Alanine aminotransferase elevated at 361 (normal high 89), indicating active liver damage within 24-48 hour period, compared to 618 in 2023. Alkaline phosphatase mildly elevated. Low total thyroid level attributed to being unwell. Unclear if this is a recurrence of previous condition or if blood sample taken earlier in the process.

Plan:
Reassess Xena tomorrow at 2:00 PM with Matt for temperature check and to assess for any changes.

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