C10002787 / invoice 20000

Appointment Notes: This morning was very flat O said has a V+ in hallway all vial, not eating hasn't seen any D+ breathing is normal but takes deep breaths here and there and sound gurgle, only started this morning but seems very flat  History: This morning large vomit and very flat since - liquid/jelly, yellow, bits of feed material but not muchIntermittently raspy, noisy breathing,Not eating or drinkingUrinated today, no defecation No concerns yesterday CE:MM pm, CRT <2sHR 180, no murmur or arrythmiaRR 40, shallow breaths, no crackles or wheezes Bilateral white mucoid nasal discharge. Abdominal palpation: distended abdomen, nausea and cough elicited on cranial palpationT: 39.4 Rectal exam: soft yellow stool in rectum Lab: CBC: mild reticulocytosis, otherwise WNLBiochem: hyperalbuminaemia, elevated ALP (x7), ALT (x2) & low Amylase. Hypercholesterolaemia although mildly improved since last test.PCV: 49X-ray: Thoracic - lung fields clear, elevated diaphragm, long segment of tracheal narrowing from L2 to larynx.Abdomen - hepatomegaly, caudal and dorsal displacement of stomach and intestines (mass effect) small stomach, adequate serosal detail.Abdominal US: massively distended gall bladder, visible from lateral wall to wall, dependent pocket of hyperechoic sludge, visible biliary tracts within liver parenchyma.Assessment: Severe external biliary tract obstruction - secondary increased intrathoracic pressure and vomiting due to mass effect. Cholestatic disease has progressed, offered referral again, otherwise euthanasia on QOL ground. O's elected euthanasia Tx: Taken home for a few hours to say goodbyeEuthanasia by lethabarb IVCremation     Vital Signs    

Appointment Notes: Check up/ follow up      SMS SentHx: Doing well at home, good appetite, feeding low fat however gets into other dog's food when Os not lookingNo v/d, consistent, brown coloured stoolsUrsofalk daily, no other meds CE: BAR, MM pm, CRT <2sHR 120, no murmur or arrythmiaRR 40, normal lung soundsLNs palpate normally,Abdominal palpation: some guarding mid/cranial abdomen, lip licking on deep palpation. Difficult to discern viscera as overweightT 38.8 Lab: Bloods: hyperalbuminaemia, elevated ALP & low Amylase. Hypercholesterolaemia although mildly improved since last test.Eepeat liver/gall bladder US: Hyperechoic sludge swirling within gall bladder, subjectively less than initial US, no evidence of mucocele or biliary distension. No thickening of gall bladder wall. Liver parenchyma is homogenous, mild hepatomegaly, no focal lesions. No free fluidAssessment: No evidence of progression of cholestasis, ursofalk and low fat diet seems to be keeping at bayPlan: Continue ursofalk as prescribedRepeat bloods & US q3months    Vital Signs    Weight: 10.84 (Patient Update);       

IDEXX Medicine specialist consultation: Thyroid results reflect euthyroid sick, not consistent with underlying hypoT. May still be an underlying endocrinopathy (HyperA), but no use testing now as unwell. Consider testing once back to full health for a few weeks. Regarding cholestasis: agree that bloods and US findings are consistent with cholestasis. Recommended: Ursodiol, low fat diet and empirical narrow range ABs for 10 days incase of infectious component.Repeat US in 2-3 weeks to check for improvement vs. mucocele formation. Also repeat liver enzymes and consider CRP at this time. If owner's interested referral for specialist US + bile aspirate for c&s. Client communication: Relayed discussion with specialist to owner. Offered referral to US specialist but O declined for now. Pebbles' appetite was much better today, ate normally this morning and a little brighter. Still on meloxicam SID. Continue for 2 more days then stop. If stops eating again contact vet and will likely trial ondansetron for nausea induced inappetence.Plan: Low fat diet: RC I/D low fat wet and dryAmoxyclav 250mg PO BID for 10 daysContinue ursofalk as instructedRepeat US & liver enzymes in 2 weeks    Vital Signs