C09998656 / invoice 10000

Reason: SURG: SVUAppointment Notes: vetcheck sent 05/03AC - 1. Ultrasound has shown a new liver nodule - approx 2 cm diameter, right beside the spine and where the oesophagus comes through the diaphragm. It is a new lesion in a different place - not scarring from the surgery. It is technically possible to FNA this (7 cm spinal needles) Hepatocellular carcinoma (the tumour she had last time is a benign tumour - depite the name) so it is unlikley to have metastasised from previous. Could be a completely new lesion.  Hepatocellular carcinoma and are impossible to differentiate from nodular hyperplasia on FNA. (See below - she ALSO has nodular hyperplasia) Haemangiosarcomas are also difficult to diagnose on FNAOnly lyphoma and heparic adnenosarcomas (the more malignant liver tumour) are easy to diagnose on FNA CT may be a better option. Surgery here is likekly to be very complicated - may need to split xiphoid? Other option to monitor size in 2-3 months.   2. She does have nodular hyperplasia of the liver - at the time of the surgery (9 months ago)  SASH took general liver biopsies as well. This could be one cause of the liver enzyme elevation. Will be permanently high and could start her on denamarin/SAMe/even ursofalk long term 3. Cushings is looking less likely - Adrenals are only 1.5 mm larger than normal. Also based on reviewing the SASH history for nodular hyperplaysia as an explanation for the elevated liver enzymes. She is not pu/pd at home. Her signs of panting can be explained simply by the organomegally/nodular hyperplasia.  4. Spleen is large but still just WNL. Thought the echotexture looked normal 5, Bladder stones are back - 1.5mm diameter. Could start her on potassium citrate. ALready on c.D. But also give home cooked food.   Moniotr these, could consider urethrohydropropulstion.Discussed all the above with the ownerOwners report has been very well at home - BAR, playing with other dogs etc. Was just a few days when she was a little off.Curent meds are gaba, paracetamol, antinol and has recently had apoquel. SASH oked paracetamol at the current dose.    Vital Signs    

Reason: Brief Check - Distended Abdomen And PantingAppointment Notes: Overdue remindersHX Booked for tomorrow for "panting and distended abdomen" Nurse called asking if owners wanted her to be checked tonight and if she is unstable we would refer her for overnight care. Presented for increase in panting over the last few days - never struggling for breath just gently panting. Is normally at home in aircon at 22 degrees. Owner noticed this afternoon on a walk that her abdomen looks a little larger. Has been eaing well Seems to need to go to the toilet more but not percieve that she is poydipsic. No vomiting.IN feb had a single organ ultrasound of spleen as felt large on palpation. Mid 2025 was being investigated for cushings disease but then during workup founnd liver tumour and bladder stones.Had liver lobe removal and cystotomy at SASH.Did have a workup for cushings and was negatvie.EX - BAR and relaxed on presentatipn. Vitals normal MMs are pink but CRT slightly prolonged?Pulses strong and PR = HR  Heart and lung sounds normalAbdomen is moderately distended, spleen palpates as large as previously, has recently been checked with single organ ultrasound. Appeared normal. No fluid wave obvious.   Quickly scanned with ultrasound - no fluid present - both spleen and liver are very large, spleen has an abnormal lacey , fine echotexture. LAB - HCT 35.6 (37.3 - 61.7) Retics low Urea 10.6 (2.5 - 9.6) ALT 142 (1 0 -125) ALKP 1695 (23 - 212) ASSESSMENT Very enlarged spleen and likely liver. This is what is giving the perception of distended abdomen, Mildly anaemic (related to splenomegally?) Currenlty non regenerative or pre regenerative Is again showing signs of cushings disease - panting and increased ALKP (though panting could simply be due to the organomegally and ALKP could be due to further liver disease/neoplasia)She does need further workup - full specialist ultrasound and likely splenic aspirates +/- liver/LNs if any abnormalities If nothing evidend coult consider repeating cushings workup?3/3Ac reported to owners Are happy to book in again with SVU +/- splenic aspirates as necessary.    Vital Signs    Weight: 13.6;       MMColour: pink;       HeartRate: 120;       CRT: 2 sec;