C10006594 / invoice 10000

HISTORY: PRESENTING COMPLAINT(S): suspect border collie collapse- full report to follow- will be organising referral to specialist practice for neurologic review (likely advanced imaging, CSF tap, serology for cryptococcosis, toxoplasmosis, neosporosis).

HISTORY:on steroids. cant control legs . could not walk . went to treendale. will have hx with him. AJL
EDUF normal?
Any v#/d#/coughing?
Current medications: 
Repeats OK? Yes/ No (If yes - # months/ criteria?)
Other:


CLINICAL EXAMINATION:
Temp:            HR:                    RR:
Demeanour: timid
BCS:   3/5   Weight assessment:                 
Mm colour:    pink            CRT:    secs
Dental grade:  0 /4
Pain score: 0/5
Sterilised? Y/N   If No >> recommended timing:
Significant findings: 
ataxia, tetraparesis, fatigue
cranial nerve function normal
no proproprioceptive deficits
patellar response normal
panniculus and anal tone intact.
no pain

ASSESSMENT: 
- neurologic issue- onset approx 4 months of age.
- maybe responds to steroids (within minutes?)/ rest

TREATMENT:
- continue pred 5 mg po q 24 h for interim

PLAN:
- referral
WEIGHT: 13.10