C09996014 / invoice 10000

Reason: Couldn't Walk At AllHistory:Here for sudden onset collapse, recumbent, appears unable to move this evening, with a 2 day prior history of acute diarrhoeaDiarrhoea yesterday and todayThen this afternoon looked like was more reluctant and slower to walk suddenly, and then went and layed down and didn't want to get up againLip licking frequently, and also starting panting lotsNo vomitingPrev medical hx:6 months ago had surgery for a septic abdomen with necrotic perforation within duodenumOn seizures- on phenobarbitone 70 mg PO BID, has been on same dose since starting for approx 2 years nowDid blood test at RV maybe in Oct 26, or at least in last 6 monthsAdvantix applied 1-2 weeks agoExamination findings:HR 120, RR panting, T38.8EuhydratedBAR, anxiousEENT clearOral: MM p&m, CRT <2s, nil oral lesionsRespiratory: Normal resp effort, normal bronchovesicular sounds bilaterallyCardiovascular: regular rhythm, clear heart sounds, moderate fem pulses bilaterallyAbdomen: comfortable, normal bladder, nil abnormalities palpablePeripheral LNs: WNLsIntegument: normal skin turgor, nil visible skin lesions, good gen coat conditionMSK: Nil discomfort on paraspinal palpation, normal movement neck in all directionsNil joint effusions palpable, nil other obvious joint abnormalities and normal ROMNeuro: -sternal recumbency and appears unable/reluctant to stand without assistance into standing position-able to stand and ambulate on own without assistance once in position, mildly ataxic pelvic limb gait-CPs delayed in both pelvic limbs- paw placement present but slow, possibly slower on left cf right. Hopping reduced both pelvic limbs.Normal CPs paw placement and hopping both forelimbs-reflexes normal (normal to hyper-reflexive) all 4 limbs-normal muscle tone all 4 limbs-normal mentation-CNs normal including normal vestibuloocular reflex, pupil size and symmetry, eye position, normal menace and PLRs (direct and consensual), normal palpabral reflexes (medial and lateral canthi) without tiring, normal facial sensation and movement. BCS 5/9Laboratory:In house handheld machinesLactate	 1.3	(0-2.5) mmol/LGlucose	 5.6	(3.3-6.5) mmol/L PCV/TP 40/70CBC/biochem + lytes in house Idexx:RBC 6.47 x10^12/L 5.65 - 8.87 HCT 41.2 % 37.3 - 61.7 HGB 14.8 g/dL 13.1 - 20.5 MCV 63.7 fL 61.6 - 73.5 MCH 22.9 pg 21.2 - 25.9 			MCHC 35.9 g/dL 32.0 - 37.9 	RDW 14.8 % 13.6 - 21.7 %RETIC 0.7 % RETIC 44.0 K/uL 10.0 - 110.0 RETIC-HGB 24.0 pg 22.3 - 29.6 WBC 13.23 x10^9/L 5.05 - 16.76 %NEU 83.3 % %LYM 9.1 % %MONO 2.9 % %EOS 4.6 % %BASO 0.1 % NEU 11.02 x10^9/L 2.95 - 11.64 				LYM 1.20 x10^9/L 1.05 - 5.10 MONO 0.39 x10^9/L 0.16 - 1.12 EOS 0.61 x10^9/L 0.06 - 1.23 	BASO 0.01 x10^9/L 0.00 - 0.10 	PLT 159 K/uL 148 - 484 MPV 11.0 fL 8.7 - 13.2 				PDW 12.1 fL 9.1 - 19.4 PCT 0.17 % 0.14 - 0.46GLU 4.26 mmol/L 4.11 - 7.95 				CREA 74 umol/L 44 - 159 UREA 4.3 mmol/L 2.5 - 9.6 BUN/CREA 15PHOS 1.38 mmol/L 0.81 - 2.20 CA 2.23 mmol/L 1.98 - 3.00 TP 68 g/L 52 - 82 				ALB 31 g/L 23 - 40 GLOB 37 g/L 25 - 45 				ALB/GLOB 0.8 ALT 65 U/L 10 - 125 ALKP 372 U/L 23 - 212     *HGGT 1 U/L 0 - 11 	TBIL 5 umol/L 0 - 15 	CHOL 4.92 mmol/L 2.84 - 8.26 AMYL 933 U/L 500 - 1500 LIPA 421 U/L 200 - 1800 Na 149 mmol/L 144 - 160 K 3.3 mmol/L 3.5 - 5.8 L Na/K 45 Cl 111 mmol/L 109 - 122 Osm Calc 292 mmol/kgAssessment:Problem list:-ambulatory paraparesis-abnormal CPs pelvic limbs, with normal reflexes, mild ataxia-acute diarrhoea for 48hrs-mild increased ALP-hx epilepsy -suspected idiopathic-paraparesis with reduced/delayed CPs pelvic limbs and ataxia localise the lesion to spine -T3 to L3 (since maybe UMN with reflexes appearing normal to increased) or possibly L4 to S3Ddx IVDD, inflammatory, infectious, neoplasia, vascularOther ddx to consider for paraparesis:peripheral neuropathy/NMJ dz- although would expect normal CPs (when body weight is supported for exam) as usually affect motor neurons/NMJ more than sensory, and shouldn't really get ataxia either (except for when appears ataxic dt weakness rather than true sensory deficit ataxia) -ddx PRN (which could relate to recent diarrhoea) vs tick paralysis (on tick prevention) vs hypoT vs hypokalemia vs myaesthenia gravisvs more cranial cervical myelopathy (C1-T2) -although unlikely as forelimb CPs appear normal, although possibly hyperreflexiveVs post-ictal neuro change, or adverse effect of medication  -unlikely as on same dose phenobarbitone for years, and no recent seizure activity ALP increase likely dt phenobarbitone therapyTreatment:IVFT LRS at maintenance rate 80 mL/hrMaropitant 1 mg/kg IV Plan:Admit overnight for supportive care/monitoring, IVFT to maintain/improve spinal perfusion, and admit to specialty teams likely IM tomorrow for reassessment and further workupClient communication:-discussed possible causes spinal pathology, and other ddx LMN/NMJ disease that cannot completely rule out at this stage-options for advanced imaging for definitive diagnosis -O opted for this with initial ballpark estimates given for imaging $5000-10000 and up to $20000 if surgical-cannot give exact quote as Casper will need to be reassessed by specialty teams and they will discuss their plan for diagnostics and treatment with costs separately-transfer to specialty team will happen in morning, and will phone with update by 10am    Vital Signs    Weight: 39.1;