C10001482 / invoice 10000

Appointment Notes: recheck - restless at night to sleep ever since cardisure started - everything else normal SubjectivePresenting Concerns:  Gizmo presented for a 3-day history of restlessness and an inability to settle, occurring primarily at night.  Owner hasn't been abler to sleep as Gizmo gets on an off the bed, whines and just wont sleep. Owner hasn't been able to measure the RRR properly as isn't settling into a deep sleep.   Historical Conditions:-   History of back and hip sensitivity.-   Recent heart ultrasound performed.  V/D/C/S:-   The owner reports one episode of vomiting after the first dose of piumobendan, but this has since resolved. Bowel movements are normal.  Current Medications:-   Recently started on pimobendan (Cardisure).-   Has previously been treated with children's paracetamol for pain as had a reaction to meloxicam.  Additional Information:-   The owner reports that Gizmo's appetite, thirst, and energy levels on walks are normal. No cognitive or behavioural changes have been noted, apart from the restlessness.Emotional Assessment: The patient was tense on the examination table but appeared more comfortable on the floor. He accepted treats during the consultation.  Abdominal: Non-painful on palpation. The patient was tense during the examination.  Musculoskeletal: Pain and tension were noted on palpation of the back and hips.  Cardiovascular: Grade 5/6 heart mumur Respiratory: Normal bronchiovesicular sounds Skin: No skin lesions or clipper rash from ultrasound clipping AssessmentRestlessness – DDx: Musculoskeletal pain (primary differential), adverse medication reaction (pimobendan), early congestive heart failure, behavioural anxiety. The clinical suspicion is highest for musculoskeletal pain given the examination findings.    Lumbosacral and Hip Pain – Diagnosed based on sensitivity and tension noted on physical examination.  Discussed possible flared up by laying on back or being turned for the echocardiogram.   Dental Disease – An incidental finding on examination.PlanMedications/Treatments:-   A therapeutic trial with paracetamol was initiated to address suspected musculoskeletal pain.-   Paracetamol (100 mg/mL liquid): Give 1.15 mL PO BID  Additional Discussion:-   If the restlessness does not improve within 48 hours, the owner is instructed to discontinue pimobendan (Cardisure) for 3 days to assess for an adverse medication reaction.-   If stopping pimobendan resolves the clinical signs, the plan is to trial a different formulation (Vetmedin).-   The risks of discontinuing pimobendan, including more rapid progression of cardiac disease and potential for congestive heart failure, were discussed with the owner.-   Further diagnostics, such as chest radiographs, will be considered if the restlessness persists to investigate for congestive heart failure causes restlessness to sleep.    Vital Signs    Weight: 7.8;       MMColour: Pink;       RespirationRate: 38;       HeartRate: 140;       HeadEyes: Normal;       Nose: Normal;       Skin: Normal;       MusculoSkeletal: Normal;       Ears: Normal;       Neck: Normal;       Heart: Abnormal (Grade 5/6 heart murmur );       Lungs: Normal (No obvious crackles or wheezing to lung soudns heard. );       Abdomen: Normal;       RectalGenetalia: Normal;       Demeanour: BAR;       Hydration: Normal;       Gingivitis: 1;       Calculus: 2;       BodyScore: 4;       CRT: 1-2;