C09985127 / invoice 10000

Reason: Not Settling At Night, Coughing. Appointment Notes: Overdue reminders  ------- Sms reply: YHISTORY:Hudson presented for re-evaluation of ongoing clinical signs including soft stools, increased anxiety, polydipsia, and a worsening cough. The owner reports that approximately two weeks prior, Hudson had an episode of vomiting over a Thursday night and the following Friday, accompanied by diarrhoea on the Friday night. He was inappetent on Saturday but resumed eating on Sunday. While his appetite has now returned to normal, his stools remain soft and sloppy.Over the past week, his anxiety has significantly increased, manifesting as nocturnal restlessness with waking almost hourly, excessive panting, and shaking. He is also drinking significantly more water. His cough has become more severe and is often followed by a non-productive retch. This cough is more prominent overnight and not associated with exercise. The owner has been administering Zylkene since the weekend to manage the anxiety.Current meds: Reflux medication twice daily, Gabapentin 200mg in the morning and 200mg at night, Zylkene (started recently), and a B12 supplement every second day.Pre-existing conditions: Known grade 3 heart murmur (since 6 months of age, monitored by a cardiologist), chronic cough (previously investigated by Dr. Josh), and inflammatory bowel disease (managed with previous faecal transplant in October/August 2025). Hudson is on a liver diet.Access to toxins eg. Rodenticide: noneTRIAGE:Mentation: Anxious, shaking.EXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: grade 3/6 left apical systolic heart murmur noted. No other abnormalities detected.Respiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Abdominal: no detectable pain on abdominal palpation, no palpable organomegaly or mass lesions noted- Rectal: Temp 38.4LABORATORY:Bloods were taken for external laboratory analysis at QML.ASSESSMENT:Hudson is a patient with multiple chronic conditions, including a heart murmur, chronic cough, and likely inflammatory bowel disease. He presented today for a history of vomiting and diarrhoea two weeks ago, with persisting soft stools. More acutely, he has developed significant anxiety, polydipsia, and a worsening cough with retching. Physical examination was largely unremarkable apart from the known heart murmur and observable anxiety.TREATMENT:NonePLAN:A comprehensive blood panel including biochemistry and complete blood count has been submitted to QML for analysis. This will allow for comparison with previous results and will help investigate underlying causes for the polydipsia, such as endocrine disease. The results will be communicated tomorrow.The owner was advised to monitor Hudson's resting respiratory rate at home and to report if it is consistently above 30 breaths per minute, as this could indicate a cardiac or respiratory issue. The owner will continue with the Zylkene as it is unlikely to be causing harm. It was confirmed that Gabapentin can be given without food.Hudson has a pre-existing appointment with the internal medicine specialist, Dr. Emily, at ARH next Wednesday. The blood results from today will be available for that consultation. The plan is for Dr. Emily to likely perform chest radiographs to investigate the worsening cough. The owner understands the importance of avoiding doxycycline / other meds before this imaging to prevent masking the underlying issue. The owner will take Hudson for this specialist appointment for further work-up and management.    Vital Signs    Weight: 13.3;