C09988576 / invoice 10000

--- 05/03/2026 10:06:29 JDV:Billing items not captured overnight    Vital Signs    

Ignore - see previous entry    Vital Signs    

Reason: Drooling, Lethargic Since This Morning New ClientConsultation Time: 6:00pm Hospital Time Period: PYREXIA OF UNKNOWN ORIGIN - jaw and bone pain, pyrexia, lethargy, hypersalivation. History:Cheetos presented this eveing for investigation of lethargy and pyrexia. This morning Cheetos initially woke up normally but over the morning was more lethargic than usual and owner noted him in the backyard rethcing non-productively - owner reported that he was just lying around, not interested in interacting. O also noted red sclera. They described an episode of "breathlessness" where Cheetos took several deep breaths and looked like he couldn't catch his breath. He returned to normal breathing after this, however, was still very lethargic. Shaking/tremblind noted. Ate normally this morning. Owners also noted: third eyelid was closed over his right eye and some hypersalivation that was potentially pink tinged. Owner took rectal temperature at home - 39.5 when Cheetos was just lying quietly. No vomiting or diarrhoea noted. Not drinking much today. Hasn't been fed dinner. Owner concerned as he purchased some powder to clean Cheetos ears and applied it this morning before clinical signs noted (unsure of brand but was a dog specific product) - no head tilt, nystagmus or ataxia. Also noted: swelling under the jaw (this had happened previously when Cheetos was 10 weeks old but this resolved with antibiotics), pain when touching the head. Toxin exposure: Owners had house sprayed for pesticides one week ago - stayed out of the home for 8 hours after. No rat bait or other toxins. No access to human medicationsNormal diet: Has a chicken allergy so eats Lamb kibble. Travel history: Relocated from Hobart 5 weeks ago Preventatives: UTD with vaccinations, Parasite prevention last given in December (unsure of brand) Previous medical history: Has had intermittent hindlimb lameness noted previously (not recently), had a heart murmur as a puppy but has been told it resolved. Last normal: When he woke up this morning Foreign body exposure: Yes, likes to eat everything and will chew on sticks. Medications: None recently. Had antibiotics at 10 weeks old for submandibular swelling. End of shift update: Ate well (Z/D low fat), pyrexia resolved after paracetamol 38.5. Still quiet and painful after methadone but not screaming as previous. Subjective:Lovely boy!! Very lethargic in consult. Squinting eyes and shaking, appears very uncomfortable. However, O took outside for walk while awaiting pre-approval and could see Cheetos outside running around. Objective:Temp:  39.6   -> 38.5 post paracetamol and fluids       MM: Injected        CRT:  1s         HR:  160       FP:   Strong and synchronous       RR: 36BCS:    5/9                Wgt:    18.8kg Pain Score (CSU):   3/4CV:  Query very low grade left sided systolic murmur when in very quiet room. No arrhythmia. RESP: Tachypnoeic but no dyspnoea    GIT:   Soft and comfortableU/G:  NADNeuro: Pupils equal and responsive. Normal PLR, normal menace. Cranial nerves WNL. Normally ambulatory. No spinal pain or neck pain (initially thought there was but was maybe pressing on sore area of mandible)M/S: No pain on flexion or extension of any joints, no palpable effusion. Severe pain (screams) on palpation of frontal bone immediately above right eye. Severe pain (screams) on palpation of left mandible near ramus. There is a palpable boney swelling/proliferation of the left mandible close to the ramus. Appears comfortable on palpation of masticatory muscles. Query odd shape of head/enlarged frontal bone but symmetrical? No pain on retropulsion of eyes bilaterally, no pain on opening mouth unless touching affected site. Integ: There is a small, old wound on the head. Ophth:  Third eyelid protrusion on the right side. LNs: Prominent submandibular lymph nodes L > R. Rest WNL.Oral examination: After given pain relief was able to assess mouth relatively well - no obvious dental disease/fractures or entry sites/wounds in oral cavity. Blood pressure: 150 - 154 systolic (Doppler)Initial Tests:INTERNAL LABORATORYHaematology RBC 5.52 (5.65 - 8.87) HCT 34.4 (37.3 - 61.7) HGB 12.6 (13.1 - 20.5) Retic-Hgb 21.2 (22.3 - 29.6) WBC 17.21 (5.05 - 16.76) Mono 1.82 (0.16 - 1.12) Biochemistry Phos 2.48 (0.81 - 2.2) CRP 65.1 (0 - 10) CK 131 (10 - 200) PCV/TS:PCV/TP 34/72, clearProblem List:1. Pyrexia2. Severe focal pain on palpation of left mandible and right frontal bone3. Hypersalivation 4. Focal swelling of left mandible5. Elevated CRP6. Mild anaemia - likely normal for puppy?7. Hyperphosphataemia - puppy vs metabolic8. Injected MMs and fast CRT - pain vs fever9. Mildly enlarged submandibular lymph nodes - reactive vs otherAssessment: Ddx: Infection (migrating foreign body/penetrating injury seems unlikely given distribution vs abscess vs osteomyelitis) vs immune mediated disease (masticatory muscle myositis seems unlikely given seems like boney pain and CK WNL vs other) vs craniomandibular osteopathy vs calvarial hyperostosis vs << trauma vs other Query significance of powder put in the ears by O - likely unrelated but unable to perform ear exam as wriggly. No other neurological signs consistent with otitis media/interna. Options Offered to Client:1. Admit for bloodwork, IVFT, analgesia, paracetamol and oral examination with view to transfer to SAIM tomorrow morning. 2. Bloodwork and outpatient supportive care with view for SAIM referral at a later date - explained that would likely not be able to be seen tomorrow. Owner applied for pre-approval with insurance and agreed to admission. Happy for medicine transfer tomorrow if needed. Estimated $1,800 for 12 hours then $2,000 - $3,000 for medicine review pending diagnostics required.  Referring Vet Communication: No regular vet as yet. Treatment: Methdone 0.1mg/kg IV Q4 Paracetamol 10mg/kg PO Q8 IVFT @ maintenance  	Plan: Ongoing supportive care in hospital until AM, consider medicine referral for further investigation. Sent owner a text during shift - tried to call, no answer. Owner has insurance but has a large excess payment due to level of cover and has some cost concerns. Elected to not perform any diagnostic imaging overnight (radiographs) given cost constraints and likely medicine referral. No current indication for antibiotics so held pending workup. NPO at midnight. Owner communication:Discussed possible differentials (infection vs inflammatory/immune mediated). Likely require some form of imaging for further investigation. No indication for antibiotics at this time but would benefit from hospitalisation for analgesia and supportive care until possible transfer to medicine team in the morning. Owner happy with plan. Shows good understanding. Emphasised that we will likely not make a diagnosis overnight but would be concerned about Cheetos at home this evening given level of pain and pyrexia. O very concerned he has caused this with ear powder and feels guilty - explained this is unlikely as his presentation does not fit with ototoxicity.    Vital Signs    Weight: 18.8;