C10001534 / invoice 10000

Reason: Referral - Head TiltConsultation Time: 15:52Hospital Time Period: History:Initially presented with an enlarged left submandibular lymph node. Was working with a Chinese medicine vet utilising acupuncture. Around one month ago owners noticed Theo had an enlarged left and right submandibular lymph node (L.R). These have had FNAs - the first was inconclusive. These were increased in size for ~10 days before decreasing in size. Theo's owners have noticed Theo's submandibular lymph nodes increasing and decreasing in size without treatment. 25/2 Theo presented to his vet as he was lethargic, not eating. Theo was reverse sneezing and drooling. He was admitted to hospital and supported with IVFT. At the time he was noted to have a middle ear infection. He was then commenced on a second antibiotic. Enrofloxacin commenced and meloxicam.04/03/26 - revisited and noted Theo had a right head tilt, hiw right lower eyelid was swollen with reddened conjunctiva and green discharge. He was noted to have a corneal ulcer. Started chloramphenicol eye ointment.07/03/26 - the right corneal ulcer had resolved when checked.Last night Theo was noted to be stumbling occasionally and flicking his legs when walking. Theo is described as drunk. Last night Theo was noted to be breathing with his mouth, mouth open, blowing out checks on exhale which is unusual for Theo.Theo's appetite has been variable. He ate well last night but would only eat when hand fed this morning. Drinking slightly less than normal. Normal urination and defecation. No diarrhoea or vomiting. Occasional lip smacking noted, this has been lifelong. No coughing or sneezing. Current medications- enrofloxacin- meloxicam- chloramphenicol eye ointment- poly tears - first dose given todayDiet: Lyca - low fat kangaroo, turkey and chicken. No raw food or bones. Occasional goat horn.No recent vaccinations, is titre tested. Last anti-parasite prevention was 10 months ago.Out of state travel includes, Tasmania, West Australia, New South Wales, Queensland.Has had BOAS surgery in 2024. Ate a a fishhook when was 8 months old. Was removed without concern.Theo had a large gastrointestinal episode, in February 2024, where Theo was vomiting, not eating and had diarrhoea. He needed hospitalisation for 7 days. This episode seemed to be associated with the feeding of raw food.Theo has known skin allergies that is managed with P.E.A (Canine sceuticals). The red paws are best managed by keeping Theo off the grass and washing his paws more often.Subjective:Objective:Temp:            MM:              CRT:             HR:             FP:              RR:BCS:    /9                Wgt:    kg Pain Score (CSU):   /4CV:    RESP:              GIT:   U/G:  Neuro:  M/S:  Integ:  Ophth:  LNs: Initial Tests:INTERNAL LABORATORYPCV/TS:(Dog: PCV 37-55%, TS 55-75 g/L)(Cat: PCV 30-45%, TS 62-81 g/L)LACTATE:   mmol/L	Blood Gas(sample type: arterial/venous)Abnormal parameters:Interpretation:CBCAbnormal parameters:Blood smear examination:BiochemistryAbnormal parameters:PT:APTT:UrinalysisCollection method: cystocentesis/urinary catheter/free catchpH:   Protein:   Glucose:   Ketones:   Urobilinogen:   Bil:   Ery:   Hb:USG:Sediment examination:EXTERNAL LABORATORYLab No: 	***** PENDING *****Sample: Interpretation:IMAGINGAFAST:TFAST/Vet Blue:Radiography:Problem List:Assessment: Options Offered to Client:Financial update:Referring Vet Communication: Treatment:  	Plan: Diagnostic plan :Therapeutic plan :Discharge plan :Referral plan :    Vital Signs