C10022025 / invoice 10000

Reason: Bloods And MedsDRAFTIntern: JLHistory: Rosie is a 13yr 10m FS Staffordshire Bull Terrier X management by the ARH oncology department for multiple myeloma. In April 2025, Rosie was presented to her RV for difficulty using the stairs. The owner also reported concerns that Rosie might be deaf or not acknowledging their presence, at that time it was considered canine cognitive dysfunction along with concurrent OA. On 28/08, she was re-presented for evaluation and management of osteoarthritis, with stiffness noted particularly in the lower back. At that visit, the possibility of trialling NSAIDs for pain relief was discussed; however, blood work was recommended prior to initiation. Blood work revealed hyperproteinemia (97), hyperglobulinaemia (74), increased ALT (181), increased GGT (10). Given these findings, protein electrophoresis was performed on 05/09, which revealed significant abnormalities: Albumin (#) 22 23 - 40 g/L LAlbumin % (#) 22.8 60.3 - 72.8 % LGlobulin (#) 76 25 - 45 g/L HAlpha-1 Globulin % (#) 3.0 1.0 - 2.6 % HBeta-1 Globulin (#) 2 7 - 13 g/L LBeta-1 Globulin % (#) 2.3 5.6 - 9.1 % LBeta-2 Globulin (#) 4 6 - 14 g/L LGamma 1 Globulin (#) 57 5 - 13 g/L HGamma-1 Globulin % (#) a 58.2 6.2 - 15.4 % Hpattern was concerning for a biclonal gammopathy. In light of these findings, Rosie was referred to ARH Oncology for further investigation. 12/9/25: Presented to ARH oncology department for initial consultation. PCV/TP 36/105. VBG WNL. CT staging performed: Findings relevant to biclonal gammopathy 1. Long bone: both femurs, both humeri: intramedullary soft tissue lesions DDx: intramedullary involvement due to multiple myeloma, less likely haematopoietic bone marrow 2. Spine: osseous lysis of Th11 with no spinal cord compression 3. Spleen: the two splenic regions have a broad aetiologies from benign to malignant however cannot exclude involvement 4. Liver mass: this findings has a broad range of aetiologies including a primary liver mass (such as hepatocellular adenoma, carcinoma) however cannot exclude involvement Other findings:1. Left caudal lobar lung mass - DDx: primary lung mass such as carcinoma 2. Cutaneous and subcutaneous nodules (1) left ventral neck, (2) both right > left brachii subcutaneous nodules FNAB liver, splenic and lung masses: VETERINARY CYTOLOGY Cytology Reference: 205-8291 Specimen: 1. FNA liver (4 slides) 2. FNA spleen (4 slides) 3. FNA lung mass (13 slides) Microscopic: 1. The smears are of moderate to high nucleated cellularity, consisting of many hepatocytes admixed with moderate to large numbers of plasma cells and occasional small lymphocytes and non-degenerate neutrophils. Plasma cells exhibit mild atypia including mild to infrequently moderate anisokaryosis, occasional binucleation, and rare trinucleation. Hepatocytes exhibit occasional mild indistinct vacuolation and contain blue-green granular pigment (lipofuscin, presumed). They are otherwise morphologically unremarkable. 2. The smears are of moderate nucleated cellularity, consisting of a mixture of small lymphocytes, tri-lineage haematopoietic precursor cells, and in some smears, increased numbers of plasma cells arranged individually and in aggregates exhibiting atypia as described above. 3. Most smears consist essentially of blood and blood component. Two smears are of high cellularity, composed predominantly of atypical epithelial cells with scattered neutrophils and macrophages in a markedly haemodilute background. Epithelial cells are arranged in clusters with occasional acinar-like formations and are polygonal with relatively high N:C ratios, distinct cell margins, small to moderate amount of medium blue lightly vacuolated cytoplasm, and round nuclei with finely chromatin and 1-2 indistinct nucleoli. Binucleation is occasional and anisocytosis and anisokaryosis are mild to infrequently moderate. Mitotic figures are not identified. INTERPRETATION: 1, 2. PLASMA CELL NEOPLASIA. 3. SUSPICIOUS FOR CARCINOMA22/9/25: Melphalan commenced at induction dosing (2mg PO SID) in conjunction with prednisolone and amoxyclav. 12/2/26: Rosie has been tolerating melphalan therapy well. The owner reported a decrease in Rosie's vision and opthamologist evaluation was recommended. Globulin level were within normal range today and her liver enzyme markers (ALT, GGT) remained staticRosie has been XXXPast pertinent history: Seizures - Diagnosed as idiopathic epilepsy - First seizure occurred at 1yr of age, no advanced imaging performed, presumptive diagnosis made. Current medications: Antinol and GlydeZydax monthly injections Pexion 400mg tablets - 1.5 tablets in the morning, 1 tablet at night. Melphalan 2mg PO EOD maintenanceMeloxicam 0.1mg/kg PO SID As required: Maropitant 40mg PO SID PRN nausea/ vomitingProkolin 5ml PO BID PRN diarrhoeaExamination Findings:Weight: 20.4T: 37.9C          P: 96bpm    R: 32bpmMM: Pink, MoistCRT: 1-2sec Demeanour: BARHydration: Euhydrated  Cardiovascular: No murmur auscultated, sinus rhythm, femoral pulses strong and synchronous, normal peripheral temperature Respiratory: Clear bronchovesicular sounds bilaterally, normal respiratory effort.Abdomen: Soft, comfortable on palpation. Oral exam: No oral lesionsEars: No inflammation or dischargeEyes: No inflammation or discharge, nuclear sclerosisIntegument: Clean coat, 2cm s/c lesion L caudal ribs - FNAB 20.11 - lipoma. 3cm mass R axilla - FNAB 16/1/26 - lipomaLymph nodes: popliteal and R prescapular palpable as previous. Gait: Able to right, rise and ambulate with normal gait, full musculoskeletal exam not performed. Neurological: BAR Rectal: NPLaboratory: PCV/TP: IDEXX inhouse CBC - see attached results HCT 37.8% 37.3 - 61.7NEU 5.05x10^9/L 2.95 - 11.64PLT 288K/µL 148 - 484Inhouse Chem 17 - see attached resultsALT 805U/L 10 - 125 HGGT 15U/L 0 - 11 HCHOL 8.76mmol/L 2.84 - 8.26 HALT 805U/L 10 - 125 HAssessment: Multiple myeloma- Biclonal gammopathy- Visceral plasmacytosis - liver and spleen - FNAB 12/9/25 - CT staging 12/9/25--> intramedually soft tisue lesions both femurs and humeri, osseous lesion Th11, two splenic lesions and a liver mass - Melphalan and prednisolone commenced 22/9/25 - Glob reduced 60g/L 8/10/25- Glob normal 39g/L 23/10/25Remained WNL since this time. Left caudal lung lobe mass - Found CT staging 12/9/25 - FNAB - suspicious for carcinoma Biochemical hepatopathy- ALT 281 U/L 29/9/25, reduced 243 U/L 8/10/25, increased 340 U/L 23/10, 317U/L 20/11, 725U/L 16/1/26, 789 12/2/26- GGT 13 U/L  12/2/26Treatment: Melphalan 2mg PO EOD maintenanceDispensed by JK , checked by KOCMeloxicam 0.1mg/kg PO SID - script providedContinue as required:Maropitant 40mg PO SID PRN nausea/ vomitingProkolin 5ml PO BID PRN diarrhoeaClient communication:Plan:Revisit in 28 day for a CBC, MBA and dispensing of further melphalan PROCEDURES: Rosie needs Gabapentin and Trazodone prior to vet visits requiring an invasive procedures    Vital Signs    Weight: 20.4;       MMColour: pink;       Temperature: 37.9;       HeartRate: 96;       RespirationRate: 32;       CRT: CNG;