C10017300 / invoice 10000

Reason: Mx- Breathing Up At TimesAppointment Notes: Quoted $370 consult feeHistory: Brought in by Maria.Presenting for upper respiratory tract dyspnoea. Started about 12/24 and has progressively worsening. Characterised by very loud upper resp tract noise. O provided a video, which starts with reverse sneezing and then stertor, this episode was the worst he's experienced, lasting about half the day. He now can't go for walks without developed the marked URT noise and it also occurs when he is excited. Prior to two years ago, he was completely normal. Snoring has increased but he doesn't snore all of the time. Cyanotic tongue has been observed. No sneezing, nasal discharge or coughing.Normal appetite. No vomiting or reflux observed. Normal defecation. He has also had episodes that O thought might be a seizure, as she has a child with seizures. They have occurred about 6 times in the last two years, not associated with the resp tract signs. They usually occur at rest, characterised by circling, disorientation, and recently, involuntary leg lifting.Current Medications: NoneExamination: BAR, MM - cyanotic tongue, HR 116, no murmur, RR panting, markedly increased upper resp effort, with markedly increased upper resp noise, stridor and stertorThoracic ausc - referred URT noiseAbdominal palpation NADSPO2 ~92%Problem List: 1) ALT elevation 1.69x 4/20, normal ALT 12/252) R MPL 12/233) URT signs - stertor, reverse sneezing 12/24, 12/254) Hx licking paws, otitis externa, conjunctivitis5) Increased upper resp noise since ~12/24, progressively worsening, increased reverse sneezing, cyanosis6) Neurological episodes - usually occur at rest, usually characterised by circling, disorientation, recently involuntary leg lifting, last a couple of minutes, have occurred ~6 times in 2 years, not associated with dyspnoeaAssessment: Marked URT dyspnoea and cyanosis. Options are for head CT and upper airway exam. O opted for GA and airway exam only. Procedure: Upper airway examPre-med: none initiallyInduction: alfaxan IV to effect, once laryngeal function was assessed, butorphanol 0.2 mg/kg was administered, then intubated, maintained on top up alfaxan with O2 via ET tubeNormal soft palateEpiglottis retroversionNormal laryngeal movementNo obvious larygneal inflammationMildly enlarged tonsilsRetroflexed scope view of nasopharynx - normal choanae, no stenosis, mild-mod erosion/inflammation of mucosa caudal to choanae, with mild bleedingRhinoscopy - no abnormalitiesAssessment: Epiglottic retroversionNasopharyngeal inflammation may be secondary to increased negative airway pressure or another issue such as gastrooesophageal reflux.Ideally recommend referral to surgeon to discuss options. O would like to trial medical management for GORD and anti-inflammatory prior and to schedule a surgery consultation. Discussed that this will likely reduce Toffee's life expectancy, that it's a rare condition, without a universally effective treatment and that the treatments can be associated with complications, however, surgery is the preferred option given the impact on Toffee's QOL. Etiology is unknown, possible causes are hypothyroid-induced neuropathy (normal T4 12/25), glossopharyngeal/hypoglossal neuropathy.Treatment: Omeprazole 10 mg in AM, 5 mg in PM for 2 weeks, then 10 mg PO SIDSucralfate 0.5 g in water PO BID 7 daysPrednisolone 2.5 mg PO BID 7 days, then 2.5 mg PO SID 7 days, then 2.5 mg PO EOD 7 dosesPlan: Internal referral to surgery    Vital Signs    Weight: 6.8;