C09999961 / invoice 10000

GapOnly Summary
In-House team to paste into OpenVPMS
Presenting Complaint
- Ongoing poor appetite and intermittent increased respiratory effort; concern for pain and progressive disease.

Prior History
- severe inflammatory bowel disease (IBD) with intermittent reduced appetite, previous episodes of diarrhoea now resolved, recent ongoing respiratory signs, and chronic medication management.

Assessment
- Open; pending ongoing management

Treatment
- Continue current  corticosteroid, dose adjusted to split dosing (morning and night).
- Ongoing diet management: Current diet is Hill's Prescription Diet z/d wet food (noted reduced palatability and interest), dry cat food increased. No renal diet given to Samwise (owner advised against sharing companion cat’s renal diet).
- Review of feasibility for faecal transplant from healthy housemate cat (pending further investigation and protocol development).
- Repeat prescription of compounded medication provided.
- Plan for follow-up phone call review in coming days regarding weight, appetite, and comfort.

Diet
- Hill’s Prescription Diet z/d wet food.
- Dry cat food incrementally increased due to declining interest in wet food.
- Eats best in evenings, often after corticosteroid administration.
- Appetite particularly poor in mornings.

Additional Notes
- Weight remains stable compared to prior visit.
- Owner monitoring faecal quality; stools generally dry with intermittent softer motion, no current diarrhoea.
- Owner aware of complexity and palliative focus in management.
- Potential for faecal transplant discussed; pending further information and safety confirmation.

Completed by Dr Oosthuizen
Consultation Date: 22/02/2026 16:08
HISTORY
Presenting complaint:
- Intermittent episodes of chronic rapid breathing
Current medications & medical conditions:
- Diagnosed with cardiac enlargement approximately four years ago
- Receiving pimobendin, benazepril, frusemide (dose recently scaled down)
- Developed diarrhoea and weight loss; diagnosed with inflammatory bowel disease via bicavity ultrasound
- Sonographer reported congenital cardiac problem, minimal changes in lungs
- Rapid breathing episodes have recurred; frusemide appears to provide some relief
Client concerns:
- Owner uncertain about cause of rapid breathing—questions about possibility of asthmatic condition given frusemide response
- Owner questions if there may be any underlying issues involving chest, lungs, or brain

PHYSICAL EXAM
Mentation: BAR
Eyes: NAD
Ears: NAD
Nose: NAD
Oral: Pink mucous membranes, CRT <2 seconds
Dental Grade: Description not provided
Lymph nodes: NAD
Cardiac: Enlarged heart noted from previous diagnosis
Respiratory: History of intermittent rapid breathing episodes
Abdominal: History of inflammatory bowel disease, weight loss, diarrhoea
Genitourinary: NAD
Musculoskeletal: NAD
Neurological: Reported as a very skittish cat, behaviour noted as twisting and turning
Skin & Coat: 5/5
Anal Sacs: NOT DONE
Temperature: NOT TAKEN
Notes:
- Chronic, intermittent episodes of rapid breathing
- Medication adjustments noted
- Owner observation: cat is "skittish," with twisting and turning behaviour

DIAGNOSTICS
- Clinical Examination
- CT imaging performed for investigation of rapid breathing episodes
- Bicavity ultrasound previously performed to assess heart and abdomen

ASSESSMENT
- Cardiac enlargement with suggestion of congenital origin
- History of inflammatory bowel disease
- Intermittent episodes of rapid breathing, responsive to frusemide
- Owner concerns regarding potential underlying chest, lung, or neurological issue

TREATMENT
- Cardiac medications to be continued: pimobendin, benazepril, frusemide (current scaled dose)
- Monitoring of response to frusemide in relation to breathing episodes
- Close observation for recurrence or worsening of diarrhoea and weight loss

COMMS
- We queries about possibility of asthmatic condition and neurological involvement

ADDITIONAL INSIGHTS
None

RECOVERY CALL
- Owners to be contacted to follow up on recurrence of rapid breathing episodes, weight changes, and gastrointestinal symptoms (diarrhoea)
- Inquiry regarding response to medication adjustments

Admission. Comms team to paste into OpenVPMS
Admission for procedure:
- Patient Name: Samwise (Male Desexed) ID: 133717
- Date: 21 February 2026
- Nurse: Izzy

Procedure to be performed:
- CT scan (contrast) of three separate body areas (head, thorax, abdomen)

Current medications or medical conditions:
- Severe inflammatory bowel disease (IBD)
- Cardiac problems
- No current breakfast (fasted; last ate at 7:30pm previous evening)
- Not vaccinated due to complex medical history
- Recent bloods performed (2 days prior)
- No vomiting or diarrhoea reported
- Normal toileting

Diet:
- Fasted for procedure
- Last meal at 7:30pm previous evening

Next contact:
- Client will be contacted by phone once CT is completed

Discharge time:
- Tentative discharge in the afternoon (after 11:30am, flexible depending on clinical course)
- Summary and CT report to be sent to client post-procedure
Notes:
Samwise presenting for diagnostic imaging due to ongoing intermittent faster breathing episodes; abdominal effort not recently observed. Sedation risks discussed, particularly in relation to cardiac condition. Recent blood testing negates need for repeat sampling on admission. Has shown normal behaviour other than respiratory symptoms.