C09987184 / invoice 10000

NOTES: Reason: Hasn't eaten in 4 days, V+, nose infection 

HISTORY:
Presented for V+ yesterday a few times with brown flecks in it 
Hasn't eaten anything in 4 days 
Unsure if urinated or defecated 
very lethargic and flat
Hard to walk around 
histroy of chronic rhintis and ulcertaurion of nose ddx auto-immune? 


EXAMINATION: 
Mentation: QAR
Temp: 39 
BCS: 8/9
Eyes: bilastral conjunctivitis, no tear production 
Ears: mild malodour 
Nose: ulceration, purulent green discharge 
Dental: Grade 3-4 dental disease present, moderate tartar present
Cardiac: HR 120, no murmur or arrythmia ausculated 
Resp: RR panting, increased inspriartor effort, no crackles or wheezes
Abdo: firm and tense on palpation 
MSK: ambulatory x4, normal gait, no lameness
Neuro: mentation appropriate, no obvious cranial nerve deficits or ataxia 

DIAGNOSTICS: Haematology + Biochem + SDMA + Lytes 4
Diagnostic results:
marked increase in ALKP
marked increase in ALT (too high for analyser to read even after dilution)
Mild increase in SDMA 
ddx primary liver vs reactive heaptopathy - diagnosis open 

AFAST:
No FF in abdomen, bladder calculi? possibly enlarge liver 

ASSESSMENT:
1. lerthargy, not eating and protracted vomiting - ddx GI (FB vs enetritis vs IBD vs other) vs non-GI (pancreatitis vs heopatopathy vs cushings vs kidney disease vs other) 

PLAN: 
Diagnsotic/treatment plan:
Options provided:
1. referral to ARH for aggressive supportive care (feeding + fluids + pain relief) + imaging 
2. humane euthanasia (extremely flat and unwell, no eating for 4 days) 
O elected option 1

COMMS:
Discussion of need for aggressive supportive care given she is very unwell - advised emergency best chance 
Offered humane euthanasia - declined for now and wanting to go starlight to ARH Gosford 
History sent  
O happy with this plan