C09995012 / invoice 10000

06/03/2026 Hx:
Doing better since going home. Jogged to his bowl this morning. more energy. improving each day. Eating happily. Stools have normal. Hasn't felt too hot. No ataxia or head tremors. Taking medications well. 

Medications:
- prokolin 3mL PO BID
- doxyxycline
- prednisolone 10mg PO SID
- ondansetron prescription if required
- enrofloxacin 10mg/kg PO SID

Exam:
BAR, BCS 4/9, HR 120, RR 24, T 38.6
MM: pink and moist, CRT < 2 sec
EENT: eyes clear, no discharge, no blepharospasm. Ears clean, no discharge, no malodour. No nasal discharge. 
CV/Resp: heart auscults clear, no murmurs noted. Clear breath sounds in all lung fields, no crackles or wheezes
GI/UG: abdomen soft and non-painful, liver does not extend beyond the costal arch. 
Integ: clean and shiny haircoat
LN: peripheral lymph nodes palpable < 1cm

Diagnostics:
1) CRP 28.9 - >100 @ presentation on Monday
2) CBC: resolution of neutropaenia 6.85, lymphopaemnia 0.6, eosinopaenia 0.01, improving thrombocytopaenia 79, MPV 15.8+, Pltcrit 0.12-

Assessment:
- Recent illness: Neutropaenia, thrombocytopaenia, pyrexia, diarrhoea, head tremors
     - BM: Granulocytic proliferation with increased blasts, maturation arrest, and moderate dysplasia, Erythroid hypoplasia, Megakaryocytic series appears normal
     - BM core: Myeloid hyperplasia with left shift or maturation arrest - suggestive of severe increase in demand/consumption (infection/sepsis) vs immune
     - CSF:  Mild recent or iatrogenic haemorrhage.
     - Anaemia PCR pending

Plan:
- Continue current medications whilst awaiting anaemia PCR
- Recheck FBE in 1 week pending clinical picture/anaemia PCR