C10004649 / invoice 10000

Presenting reason: Lethargy and decreased responsiveness

History:
Acute onset of lethargy this morning, showing decreased movement and interest in eating / drinking. Last defecation was the previous night with normal stools. No v+. Daughter suspects has been drinking more recently in the hx building up to today. Previous d+ issue resolved last month straight away. Occ scavenger but no recent hx of him doing this. No access to rat baits.
Current meds: fish oils, no prescription meds.

Examination: 
Demeanour: QAR, no interest in treats from me but took a couple from o. Walked in but immediately lay down.
HR: 128bpm, auscultation difficult with trembling but no obvious murmur, synchronous peripheral pulses.
RR: Respiratory: clear lung sounds, no crackles, wheeze, normal respiratory effort.
T: 38.6
MM: pale pink but slightly tacky CRT: <2sec. 
Eyes: NAD
Ears: NAD
Dental: g2-3/4
Abdo: Tenses on cranial abdo palp.
MSK: Trembling in HLs +++. Weakness in hind legs (delayed CPs, both legs), history of possible arthritis (see previous MSK exam, did not do full MSK exam today)
Integument: Good condition
LN: NAD
Rectal: soft stool, no masses palpated.

Problem list:
1. Acute onset of lethargy and decreased responsiveness, inappetence
2. Mild dehydration (5% estimated)
3. Abdominal discomfort
4. Hind leg weakness (previously noted, DJD vs spinal vs others)
5. Dental dz

Plan:
Suggested running blood tests (GHP + CRP). Consider referral to an emergency clinic for further diagnostic workup. O's wanting bloods with us first to decide if they want to go to an emergency clinic.

Note: This clinical record was partially created using speech recognition transcription software and has been reviewed for accuracy.

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GHP + CRP bloods:
HAEM:
-Mod non-regenerative normocytic normochromic anaemia. Hct 0.279 (RR 0.373-0.617).
-Marked thrombocytopenia <50 x10^9/L (couldn't see any obvious platelets on blood smear). No obvious petechia and ecchymoses noted (although did not re-examine post-bloods to check as heading to emergency).
-Agglutination and spherocytes were not detected.

-"This platelet estimate incorporates enumeration of individual platelets and platelets within clumps. With the exception of canine patients with congenital macrothrombocytopenia, markedly decreased platelet counts (less than 50 x10^9/L) place the patient at risk of bleeding from surgery/trauma or spontaneously (especially if there is a concurrent platelet function defect or platelets are less than 30 x10^9/L). Evaluate the patient for petechia and ecchymoses. Consider immune-mediated thrombocytopenia (primary and secondary) for markedly decreased platelet counts. If this finding is unexpected, please redraw a new sample to rule out artifactual thrombocytopenia (e.g., clot in the blood tube)."

-There is no evidence of RBC regeneration in response to the anemia at this time. Consider pre-regenerative anemia or causes of nonregenerative anemia. Continue monitoring the CBC for development of a regenerative response."

BIOCHEM:
-Mild elevation in ALP 236 (RR 23-212)
-Otherwise all WNL.

CRP: 98.4 (RR 0.0-10.0)

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Updated problem list:
1. Mod non-regenerative normocytic normochromic anaemia
2. Marked thrombocytopenia on in-house bloods
3. Sig CRP elevation 98.4
4. Acute onset of lethargy and decreased responsiveness, inappetence
5. Mild dehydration (5% estimated)
6. Some cranial abdominal discomfort
7. Hind leg weakness (previously noted - likely worse during PE today due to anaemia)
8. Dental dz

Discussed blood results with o's. ?ITP / IMHA / evans / haemorrhage / neoplasia etc. Since so lethargic and we are closed, rec o's elected to head to Murdoch University tonight for further workup. Spoke to someone from Murdoch emergency who is happy for Bongo to go there.

REASON: Diarrhoea & off food

S: Deb presented with Bongo. 2d hx of being off his food (still eating small amounts, but usually is a big foody, so v unlike him). Also has had some v smelly d+ for last couple of days. Was down south last weekend and had a couple of v+ down there but was otherwise well. Is a known scavenger and could have easily eaten mulch / picked up something down there. No recent obvious v+, although did have a poss biley looking v+ with grass in it seen 2d ago, and Mr reports poss did v+ up some water after drinking. Food seems to be staying down. O reports she has been encouraging him to drink (although mentioned daughter thinks that poss PD prior to this happening). Energy okay, not lethargic but fluctuating energy and not quite himself. Does drink salt water from their swimming pool. Not on any meds. Otherwise had been well. Due parasite control (o has a monthly chew at home and will give this today).
Current diet: R/C dental kibble.

O: BAR, good dog. MM: pink + moist. CRT: 2s. Dental: grade 2-3/4 (multiple previous exts, rec dental s&p in future). HR: 100, no murmur. Resp: clear, normal BV sounds. Abdo palp: comfy, NAD. Temp: 38.4C. LNs: WNL. Rectal: blood-tinged soft stool on glove, empty, prostate WNL.
MSK:
-V shaky HLs reported by o, but was trembling +++ for exam too today.
-Mildly delayed L HL CP replacement, R okay.
-Mild muscle loss in HLs but symmetrical. HL & FL joints all move pretty well for age. Symmetrical FLs & HLs.
-Spinal palp: slight sensitivity mid lumbar palp. Cervical spine ROM WNL.

A: Problem List:
1. 2d hx of d+ and inappetence (+ occ v+)
DDx: Primary GI (ie dietary indiscretion, infectious, obstruction, early IBD, GI ulceration, neoplasia, HGE etc); vs Secondary GI (ie pancreatitis, peritonitis, prostatitis, hepatobiliary dz, renal dz, endocrine – Addison’s etc).
2. Poss hx of PD prior

P: Discussed symptomatic management vs further investigations. Rec bloods as older dog & considering GA in future for dental & poss hx of PD, o will consider this in future. O elected to treat symptomatically today. Discussed Pro-Kolin +/- AB therapy. O’s elected to commence both. O to feed bland diet (o going to try the R/C gastro kibble - purchased OTC sale). Dispensed Pro-Kolin to give BID (until d+ has stopped). Dispensed 5d course of Metronidazole. INB: discussed faecal PCR, bloods/urine, imaging etc. O happy with plan.

O also took home faecal pot & urine pot as will consider bringing in stool INB but otherwise fine. O may consider bringing in first morning urine for UA/USG (if USG low will do bloods).

CC3-5d to ensure improvement.

JJ :  #5F body and legs. #7F belly. 10mm reverse on head. Trimmed feet, ears, face and tail. Nails. AG done.