C09988350 / invoice 10000

Reason: Urine dropped off by O at request of Dr Will for further investigtionReceived by LS and sent to IDEXXLS    Vital Signs    

Reason: Idexx Results Attached To FileAppointment Notes: LSHistory:Discussion regarding ongoing management of idiopathic IMPA.BT showed the following:CBC unremarkable, no evidence of BM suppression from lefluonmide useBiochem showed further improvement in ALKP levels after cessation of prednisolone - reducef rom 1400 to 796. CRP still mildly elevated at 15.9.Plan:1. idiopathic IMPACookie is suspected to be in the 30% of cases that do not achieve remission and will likely require long-term medication.Referral to an internal medicine specialist for a second opinion to confirm the current management plan is appropriate and that no other options have been missed (eg adding another immunosuppressive drug).  The owner is to call the specialist to organise an initial consultation. This practice will send the clinical notes upon request.A decision on ongoing management will be made after receiving the specialist's report and discussing options with the owner.Titre testing will be deferred and organised until after the specialist review, poending Specialist's reocmmendations for vaccinations.  Need to check UA as well , as we would have been on leflunomide for about 3 months, to ensure we do not have a asymptomatic UTI brewing from immunosuppression.   Forgot to mention this to owner during phone call, so I have sent this in bold and highlight in my email communication as belowOwner happy with plan.   Dear Stella,I’ve summarised our discussion below to help you remember what we covered.  I've also attached Cookie's latest blood test results for your records. Topic/Issue #1: Ongoing Management of Immune mediate polyarthritisDuring our discussion, we talked about the management of Cookie's idiopathic immune mediate polyarthritis. This means that based on how things have progressed, it seems unlikely that the condition will go into complete remission. It is important to understand that this means Cookie will likely need to be on medication long-term to manage the symptoms. For now, the plan is to continue with the current medication at the same dose without any changes.Topic/Issue #2: Referral for a Specialist OpinionAnother key point we covered was getting a second opinion from an internal medicine specialist. This is to have an expert review Cookie's case to confirm that our current approach is the most reasonable one and to see if there are any other options we might have not explored. The specialist will review all the information we have and provide their recommendation. They might suggest adding another medication, but we will need to carefully weigh the pros and cons, as using two immunosuppressive medications can increase the risk of side effects.Topic/Issue #3: VaccinationsWe also discussed vaccinations and titre testing. To address this, we have decided to put these on hold for now. We will wait until after the specialist review to decide on the best time for titre testing and any necessary vaccinations.Next Steps:I will send you a text message with the contact details for the internal medicine specialist at Underwood.Please call them to organise an initial consultation for Cookie. You can let them know that I have recommended the referral to discuss immune mediate polyarthritis. They will then contact us for Cookie's medical notes.In the meantime, please continue with Cookie's current medication at the same dose.Once we receive the consultation report from the specialist, we will arrange another consultation to discuss their recommendations and decide on the next steps together.**** I forgot to mention in our phone call earlier, **_if you are able to drop off some urine sample from Cookie at some stage that'll be appreciated, as that is also part of the monitoring for long term Leflunomide use, to ensure there's no brewing UTI from using the immunosuppressive medication.  _**Thank you for trusting me with Cookie's care. If you have any questions or concerns about anything we discussed, please do not hesitate to reach out.Warm regards,Dr. William Chan    Vital Signs