Initial Consultation Prior to Canine Chemotherapy Template

NEW CONSULTATION PRE-CHEMOTHERAPY FOR DOGS  -   2023-10-15 by Dr. Emily Carter.
Presentation
- Referral for chemotherapy assessment from Dr. John Smith due to a lymphoma diagnosis.
Pre-referral diagnosis
- Diagnostic tests conducted: CBC, Biochemistry, and Ultrasound. Results show elevated lymphocyte count and enlarged lymph nodes.
- Metastasis screening: Thoracic radiographs reveal no signs of metastasis.
- Paraneoplastic pathology screening: No abnormalities found.
Owner relevant history
- Presenting clinical signs: Lethargy and reduced appetite for 2 weeks.
- Response to treatment: Partial improvement with corticosteroids.
- Current clinical status: Stable but lethargic.
Previous history
- Length of ownership: 5 years.
- Desexing status: Neutered.
- Preventative care status: Up to date.
- Vaccination status: Current.
- Travel history: No recent travel.
- Appetite: Decreased.
- Diet: Commercial dry food.
- Water intake: Normal.
- Urination: Normal.
- Defecation: Normal.
- Vomiting or diarrhea: None reported.
- Cough or sneezing: None reported.
- Allergies or adverse reactions: None known.
- Seizure or collapse events: None reported.
- Exercise tolerance: Reduced.
- Fasting status: Not applicable.
- Previous medications: Corticosteroids.
- Previous noteworthy illnesses: None.
Additional tests
- Urinalysis results: Normal.
- Urine culture results: Negative.
- Hematology results: Elevated lymphocytes.
- Biochemistry results: Normal.
Presenting medications
- Prednisone, 5 mg, once daily, oral, last administered 2023-10-14.
Physical examination
- Body weight and body condition score: 25 kg, BCS 4/9.
- Coat condition: Normal.
- Musculoskeletal system: No abnormalities.
- Demeanor: Calm.
- Gait: Normal.
- Eyes: Clear.
- Ears: Clean.
- Nose: Moist.
- Oral cavity: No lesions.
- Integument: No abnormalities.
- Peripheral lymph nodes: Enlarged.
- Cardiovascular assessment
 - Mucous membranes: Pink.
 - Heart rate and rhythm: Normal.
 - Heart murmur: None detected.
 - Femoral pulses: Strong and regular.
- Respiratory rate and effort: Normal.
 - Upper airway: Clear.
 - Lung sounds: Normal.
- Abdominal assessment
 - Abdominal palpation: No masses detected.
 - Urogenital examination: Normal.
 - Rectal examination: Normal.
 - Prostate palpation: Normal.
- Rectal temperature: 38.5°C.
Practicalities of chemotherapy
- Client interest in chemotherapy: High.
- Intended chemotherapy protocol and drugs: CHOP protocol.
- Discussion of general drug complications: Discussed potential side effects such as nausea and immunosuppression.
- Discussion of specific drug complications: Vincristine may cause peripheral neuropathy.
- Advice against raw feeding during treatment: Advised.
- Client pre-chemotherapy concerns: Concerned about side effects.
- Practical chemotherapy concerns: Discussed frequent visits for treatment.
- Fasting status for intended chemotherapy: Not required.
Important information
- Patient anxiety level: Low.
- Raw food diet status: Not on raw food diet.
Pre-chemotherapy organ dysfunction
- Gastrointestinal
 - Vomiting or diarrhea history: None.
- Renal: Baseline creatinine level: 1.2 mg/dL, normal.
- Cardiac: Cardiac auscultation findings: Normal.
- Hepatic:
 - Baseline ALT level: 45 U/L, normal.
 - Baseline bilirubin level: 0.3 mg/dL, normal.
- Hematology:
 - Baseline PCV: 45%, normal.
 - Baseline platelet count: 250,000/µL, normal.
 - Baseline neutrophil count: 7,000/µL, normal.
Diagnostic Tests
- Blood gas results: Normal.
- CT thorax results: No abnormalities.
- CT abdomen results: No abnormalities.
- Prostate wash cytology results: Not performed.
Problem list
- Lymphoma.
- Lethargy.
- Decreased appetite.
Plan
- Step 1: Initiate CHOP chemotherapy protocol.
- Step 2: Monitor CBC and biochemistry weekly.
- Step 3: Schedule follow-up in 2 weeks.