C09998565 / invoice 10000

10 yr FS Cavoodle presents for ACTH stim test. Has been on trilostane (30mg) = last dose 5:30am, but Os have noticed decrease in energy, decrease in appetite and just not seeming right. No vomiting or diarrhoea. O would like beransa dose due to increased pain in the hips

QAR
MM pink CRT<2seconds
130bpm, grade III/VI systolic murmur LHS
Abdo uncomfortable on palpation
Stiff in both hips - R worse than the L 

Admitted for ACTH stim test
Opted to take sample for comprehensive blood test 
-> Non regenerative anaemia
-> Eosinophilia 
-> Mildly elevated ALP (427 - prev >2400)
-> Mildly elevated ALT (125 - 10-118)
-> Azotaemia - elevated BUN + CREA (22.2 and 208 respectively)
-> Elevated calcium (3.41 - 2.15-2.95)
-> Na:K ratio low - 26:1
CONCERN FOR ADDISONs DUE TO NA:K RATIO

Synacthen [0.25mg/mL] ()mL given [5ug/kg IV or 0.02mL/kg]

Resting blood test @ (9):(34)am
1 hour post blood test @ (10):(34)am

Kept on fluids for the day due to presence of azotaemia, started at high rate of 49mL/hr and then dropped to 27mL/hr after a few hours due to heart murmur. 
Advised to stop trilostane. 
No beransa given due to the presence of azotaemia and being systemically unwell
Await blood test results

--

QML results came whilst patient still in hospital

ACTH STIMULATION TEST
TIME (Hours) CORTISOL (nmol/L)
0 56 (30-90)
1 42
NORMAL DOG:
Post-ACTH cortisol: 165 - 320 nmol/L
DIAGNOSIS OF HYPERADRENOCORTICISM (CUSHING'S DISEASE)
(with appropriate clinical signs and/or other laboratory results);
Post-ACTH cortisol > 320 - 350 nmol/L

Advised break for cortisol for 1 week due to suspicion of hypoA (ACTH stim test still WNLs, but as was in hospital and was otherwise unwell, could be artefact?), then recheck that electrolytes are coming back to normal. Then if ALP increases again, restart trilostane at a much lower dose. Also offer referral - can ensure adequate management of adrenal issues.