C10031381 / invoice 10000

History - Sudden onset of head tilt and loss of balance.Vomited once.Softer stool.Seems to have improved since last night with respect to able to stand unassisted now.Physical exam -Left ear down/Nystagmus - fast phase to R.Ears clear, TM intact.Heart ok, gums pink, no signs of dehydration. bright and allert, no proproception deficits. Happy.Assessment - Vestibular dz - geriatric vestib dz, intracranial space occupying dz, middle ear dz.Plan -Start with supportive care at home and see how things go in 72 hours.Prevomax s/cRevist on 72 hours if not improving - Sat .Options include bloods including T4 and/or referral CT etc.** Vomited in car park - went and examined dog - gums good and seemed happy.Allow 1hour for Prevomax to take affect and if still vomiting at home can add in metomide and/or ondansetron.

Hx:presented for annual vaccinationcoughing improved following medicatio course, has since stopped and cough has not worsened. ~ 1 episode/daymobility deteriorating, previously had carttrophen course 5/25, doesnt think made significant differenceotherwise well, EDUF normalEx:BARBCS: 6/9MM: pink, moist CRT<2TEMP:CVS: HR 114,no murmur or arrythmia auscultated, SSFPRESP: RR 18, clear bronchovesicular lung sounds, normal effort/rate.OCULAR: nsfORAL: G3/4EARS: nsfLN: nsfABDO: soft, comfortable.MSK: HL sarcopenia, reduced ROM and discmfort hip palpationNEURO: nsfUROGEN: nsfINTEG: nsfAx: fit for vaccinationOAPx:Discuss OA management - avoid NSAID with elevated UREA/liver enzymes and if requiring steroids for coughgabanpentin vs beransa, elect to trial gabaTx:Nobivac Pi2/BB SC (B: Exp: )gabapentin 100-200mg BID

Hx:presented for coughing, chronic in nature (~9-12 months) but notably worse over past 2-3 days. increased frequency with terminal retchpresented to GARS last night and dispensed linctolno dyspnoea or exercise intolerancedrinking increased (months), unsure urinating, appetite and stools normalmobility deteriorating, responded well to cartrophen courseEx:BARBCS: 6/9MM: pink, moist CRT<2TEMP: 38.4CVS: HR 114,no murmur or arrythmia auscultated, SSFPRESP: RR panting, clear bronchovesicular lung sounds, normal effort/rate. no tracheal sensitivityOCULAR: nsfORAL: G3/4EARS: nsfLN: nsfABDO: soft, pendulous, comfortable. no obvious mass or organomegaly palpableMSK: no lameness observed, full exam not performedNEURO: nsfUROGEN: nsfINTEG: multiple soft mobile lumps, ~ 2x2cm raised black dermal mass right flankPx: admit for further diagnostics, chest rads + bloods under sedationCBC/Biochem- mild normocytic normochronic non regenerative anaemia- elevated BUN- mild elevation ALT/ALPUAUSG 1.021+3 protein DDx: pre-renal vs renalChest Rads- bronchointersitial pattern- mild tracheal narrowing at thoracic inlet left lateralAbdominal U/S- multiple hyperechoic nodules in liver parenchyma DDx: benign (nodular hyperplasia, hepatoma, lipid) vs malignant dz- solitary small hypoechoic nodule splenic head- few enlarged mesenteric LN'sAx:1. cough - suspect primary chronic bronchitis +/- bronchiectasis (cocker spaniels prone) +/- respiratory infection causing recent worsening of symptoms2. elevated hepatic enzymes/ hepatic nodules DDx: benign vs malignant priumary liver disease vs extrahepatic (pancreatic/biliary) vs endocrine (hyperA)3. solitary splenic nodule DDx: benign vs malignant4. elevated BUN DDx: prerenal (GIT haemorrhage) vs renalTx:doxycycline 100mg BID 14dprednisolone 10mg SID 7dcartrophen 0.55mlPx:r/c 7d to assess response to treatment or sooner if concerned symptoms worsening