C10009155 / invoice 10000

Reason: recheck coughing

Consult - General
PRESENTING COMPLAINT:  
(recheck coughing)

SUBJECTIVE/ HISTORY:
Presnted today with Sam for a recheck after being seen at EVH. Initially had suspected viral URT infection, however became acutely unwell and presented to emergency. Radiographs showed evidence of pneumonia, as well as a dilated distended oesophagus andn a nodule centrally over the heart base (although only seen in one view). he had been on doxycyycline - finished around a week ago, but he has started to cough occasionally again. Harsh cough with terminal retch, occasionally productive.
Very occasionally is regurgitating as well - mostly after exercise. owners feeding from a height at the moment to help.
Eating well, bright in himself, passing normal faeces.
  Appetite: (normal)
  Water Intake: (normal)
  Urination: (normal)
  Faeces: (normal)
  Current Medications: (none)
  Vaccination Status:  (UTD)

OBJECTIVE/ EXAMINATION:
Temperature:( wouldn't tolerate taken today)
Mentation (BAR) BCS:(4)/9, some muscle wasting over termporal region
Hydration:(good)
Mm pink and moist, CRT <2 sec
Dental:(grade 1)
Oral exam: (NAD)
Eyes: (clear)
Ears: (NAd)
HR: (120) bpm, rhythm (regular), Mumur (no), pulses (good, synchornous)
RR: (30) pm, effort (none), Aus pulmonary fields (slight crackles on ausucltation of chest field (L>R), and slightly harsh bronchovesicular sounds)
Abdominal palpation: (comfortable, NAD)
Integ: skin and coat healthy, no obvious lesions or lumps noted, normal skin recoil
Msk: (NAD)
Peripheral LNs: (normal, no enlargmenets)
Neurological: a full neurological exam not performed

LABORATORY:
(none pefomred)

ASSESSMENT/ PROBLEM LIST:
1. Resolving pneumonia: ddx  underlying cause incl. secondry LRT from viral disease vs aspiratory - ith large oesophagus cannot rule out megaoesophagus (ddx primary vs secondary - ie focal MG, endocrine pathologoy)
2. Nodule over heart base: ddx neoplaisa vs lymph node

DD's:
()

TREATMENT:
1. Onto amoxyclav at 20mg/kg bid 500mg for 14 days

PLAN:
1. Recheck in 3 weeks for follow up radiographs
2. If evidence of oesophageal disease - recommend referral for medicine for fluroscopic exmination +/- further tesitng
3. If any deterioration in condition, recheck here sooner. 

OWNER COMMUNICATION NOTES:
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