C09995591 / invoice 10000

Reason: BP +/- BloodsHistory:Recheck consultation for management of hypertension. Billie has been well, appetite normal.  Current medication is amlodipine 5mg, three-quarters of a tablet once daily.Examination:Body condition = 5.5/9V nervous BP = 162 #3 LFL sitting on Rebeccas lapRespiration panting Laboratory: ALP 439, ALT 137 (both similar to prev)BUN 21.4, Crea 166 (similar to her recent 'good' levels)Assessment: we dicussed whether to aim for perfect BP control by trialling new meds or being happy with nearly good enough. As she is very nervous here (way more than average) we decided to stay with current meds. Will move on to step 2 which is UPCR.Plan:Continue current medication regimen of amlodipine 5mg, three-quarters of a tablet once daily.Collect 3 samples of urine over the weekend - on Monday/Tuesday when she drops it off we will combine equal volumes from each pot and send for UPCR/UA (PAID ALREADY)Recheck blood pressure in one month    Vital Signs    Weight: 7.9;       

Reason: BP And Bloods (Crea, Lytes)Client Communication: Spoke with Rebecca about the creatinine being higher than ideal after addition of enalapril. Discussed options including full referral, rpt referral consult and trial of lower dose enalapril. Decided on rpt referral consult w vets north. Plan: Reduce enalapril dose to 1.25mg bid until advised further BW to contact Vets North with further query.Hello again, Thank you for your recent advice on this case on 29 Jan 2026. Anna Dengate provided the initial telephone advice on antihypertensives in Sep 2024, but Tunbi Vere replied to my most recent query about this patient via Vets North website in Jan 2026. After I received your response I rechecked creatinine, off telmisartan. The creatinine had reduced again, suggesting the increase in crea between Sep 2025 and Jan 2026 was primarily Telmisartan. She remains proteinuric so I started her on low dose enalapril, but her creatinine increased again by 44% to 225. Her BP was only 130mmHg on the enalapril though!I am wondering what is the best medication regime to treat her hypertension and proteinuria? Please see recent clinical notes immediately below, and the older (May 2024-Jan 2026) notes below that!Thank you, Bronwyn6 Feb 2026:Billie is eating normally; appetite improved since stopping telmisartan on 23 JanBP = 160mmHg in clinicLaboratory: crea 156 (35-141), BUN 23.2 Assessment: crea reduced, now similar to recent results (over last 24mo), though at the higher end. Certainly improved from last reading of 240 on Telmisartan. Borderline hypertension vs white-coat hypertension. Consider recheck BP at home once urine results have come in. 11 Feb 2026:Laboratory: UPCR = 1.3 UA and sediment non-inflammatoryAssessment: per Vets North: add in ACE-i or ARB (at half dose) to treat the proteinuria. Plan: continue current dose amlodipine and add-in enalapril at 2.5mg bid (0.33mg/kg bid)20 Feb 2026:Billie is eating well. Enjoying walks, active. BP = 130mmHgLaboratory: Crea 225, BUN 38.9, K 4.2 (3.8-5.6)Assessment: BUN and crea have increased again. (44% increase in crea)I'm not sure whether to: 1. reduce the enalapril by 25% down to 0.25mg/kg bid2. Halve the enalapril3. Completely change antihypertensives/antriproteinurics. Owner has agreed to consult the specialist again for opinion about this. For now, I decided to halve the enalapril to 0.16mg/kg bid) while I await specialist advice.******Problem list: Near-blind (PRA)AtopyCKD stage II proteinuric (April 2024)Hypertension (Sep 2024)Arrhythmia - sinus node disease (atropine responsive) Sep 2024Acute pancreatitis (Sep 2024) - specially formulated low fat renal diet since then********Clinical notes May 2024 - January 2026Relevant history below (each change in BP meds was followed with recheck of BP and crea ~14d later but not recorded below)May 2024 - Elevated SDMA and UPCR 1.2, dilute urine. Started renal diets- ECG for asymptomatic irregular arrhythmia - Mark Kittleson (cardiologist on VIN) suspected SND- BP 165mmHg. Started telmisartan 1mg/kg sidSep 2024 - BP 170mmHg  Changed to enalapril 0.5mg/kg bid (stopped telmisartan due to cost)- BP still 165mmHg so incr enalapril to 0.6mg/kg bid - Acute pancreatitis (Vets North abdo u/s; also suspected CKD) and 2o pleural effusion, treated at TPS. Moved to low fat renal diets (vet nutritionist formulated)- Once recovered from AP, atropine response test induced sinus tachycardia of 170bpm- BP 185mmHg; spoke with AD (Vets North) and changed to amlodipine at 0.1mg/kg bid. Crea increased by 12% so dose left unchanged. Jan 2025- BP 165mmHg (meds not altered)April 2025- BP 175mmHg; increased amlodipine by 50% to 1.875mg (0.24mg/kg bid)5 Dec 2025- BP 165mmHg (meds not altered)7 Jan 2026- BP 165mmHg. Added telmisartan 1mg/kg sid to current amlodipine dose of 0.24mg/kg bid23 Jan 2026- BP 130mmHg. Much more relaxed during BP measurement than usual. Not panting at all. Has lost 200g in 2 weeks. Os report eating less in the morning since starting new medication, but overall daily food intake is unchanged. Sleeping more deeply and appears more relaxed. Not getting up at night. Requires prompting to go outside in the morning. Normal energy and demeanour when awake and at the park.Laboratory: crea 240, BUN 41, ALT 114, ALP 468Assessment: Crea has doubled from last reading 4m ago (121umol/L); worse than when dehydrated with GIT disease 5mo ago (177umol/L). ALP is nearly double reading from 4mo ago but still only mildly increased.I stopped the telmisartan (remains on amlodipine at 0.24mg/kg bid) while awaiting specialist advice on mgmt of hypertension.    Vital Signs