C09989231 / invoice 10000

History:
Federica advised that from New year Fried Rice has been having intermittent cystitis signs and has been to a vet hospital three times to treat. He improved after new year for about 3-4 weeks but then since then the clinical signs recur a few days at most after stopping the medications which consists of gabapentin and buprenorphine. Blood and urine tests were done in the first instance, and apparently SDMA was elevated but all else was Ok, and not sure on the urine results, but not cultured. On brief ultrasoun at the time apparently the bladder was very small but that's all Federica knows. Last night and this morning he has been straining again, but just before we arrived he emptied his bladder with reasaonable volume. For the last month or so he has continued to lick around his penis every day, even when the other clinical signs of pollakiruia and stranguria temporarily resolved. Federica also advised that when he was very young he was apparently partially blocked and treated for cystitis, but nothing since. He has not vomited, appetite is Ok and he is otherwise Ok, though does have mild intermittent probs with his gut. He had diarrhoea later last year, but though stools are sometimes soft, he currently does not have any diarrhoea.

Examination:
QAR, very calm and friendly though getting a little bitey with nail clip. Vitals unremarkable, Tb not done. Abdo palp unremarkable, bladder very small. Body score 6-7/9, muscling Ok. Rest exam Ok.

Assessment:
Recurring signs cystitis, unknown cause at this time, not blocked. Limited investigation/s to date, and treatment is not helping to resolve the signs for any decent period of time.

Plan:
I advised that it would be preferable for Fried Rice to have more of a workup as soon as possible, including urinalysis and culture, and an ultrasound to examine more fully for any underlying cause. In meantime to continue with treatments:
1. Buprenorphine 0.2ml (0.06mg) transmucosal q6-12hrs at least 3-4 days
2. Gabapentin 100-150mg bid at least a week, and can consider using lower dose ongoing
3. Consider fluoxetine
4. Would like to use meloxicam, however need better assessment of renal function and imaging.

History:
Federica reported Fried Rice is due for annual health check and vaccine boosters. Had F3 last year and appears to get same every year. Never goes into a cattery and strictly indoor and porch enclosed outdoor area. Appetite/toileting Ok but has history of inappetance, sometimes with nausea and has been tentatively diagnosed with possible IBD. Is fed solely wet foods and meats and has been trying to control the gut with diet somewhat successfully. Also has been chronically licking/itchy and gets sores/scabs on nose intermittently. Not on regular flea control as Federica is concerned about chemical toxicity, but does do intestinal worming.

Examination:
BAR, very sweet cat, shy. HR-PR=136, No murmur, MM pink, CRT <2, RR 48, RE 0/3. Body score 6/9, muscling Ok. Abdo palp unremarkable.  Nasal planum non-pigmented with scattered black freckles, small ulcers/scabs in places and similar small ulcers around upper lip, chin possibly slightly swollen, but otherwise Ok. Possibly ORLs over raised reddened gums, moderate dental calculus in places. Rest exam unremarkable.

Assessment:
Overall appears systemically well. History of intermittent intestinal signs including inappetance and vomiting, may be primary GI/inflammatory disease vs other eg. food allergy, intolerance etc. Persisting pruritis may represent atopy or other allergy, eg. food, and may also be contributing to the oral/llp lesions, but the nose seems also likely to be an allergy or immune-mediated condition. Consider eosinophllic granuloma, and lack of flea control may be contributing to the general pruritis etc.

Plan:
1. Discussed vaccination frequency and elected to forgo the cat flu vacc for now, and just to F3 triennials.
2. Strongly recommended flea control - Bravecto Plus. To do this prior to considering pred trials for the pruritis and/or intestinal issues, but I'd prefer to work up the gut further before considering pred etc. for that.
3. Also discussed food elimination trials, though has already been doing a lot of dietary trials, to concentrate on single proteins if possible.
4. To update me in a few weeks after placing on good flea control to discuss clinical signs.