C10003578 / invoice 10000

HISTORY: Presented for: occasional coughing 3x day, presented for heavy breathing at night. Started 2 weeks ago
EDDU: normal
Vomiting/diarrhoea: none
Coughing/sneezing: coughing/wheezing
PU/PD: none
Current meds: none
Indoors only

Physical exam:
BCS:  5/9
Demeanor: BAR
Oral: crt<2s, mm pink and moist, grade 1/4 periodontal disease, no intraoral lesion or foreign body
Eyes: no evidence of ocular disease
Ears: clean
Cardiovascular: HR140-SR, no murmur, FP s/s
Respiratory: RR<30, normal respiratory rate and effort, normal lung sounds on all fields, normal laryngeal/tracheal auscultation. No spontaneous cough/sensitivity on tracheal palpation.
Abdomen: comfortable/no abdominal guarding, non-distended, no obvious masses
Integument: coat excellent
Musculoskeletal: unremarkable, no evidence of lameness, limbs palpate normally, normal ROM on C-spine and hips, no pain across cervical/lumbar spinal palpation or tail
Neurological: unremarkable
Lymph nodes: no palpable peripheral lymphadenopathy
Rectal: not assessed
Rectal temp: 38.6C

Assessment:
Coughing/wheezing: infectious, vs inflammatory/feline asthma

Treatment:
Doxy trial 1 notch PO SID for 10 days

Plan:
O to report back in 1 week with response. May need longer course if doing well.
If no improvement, advise in for sed + xrays.
WRMRQ: N
FLRQ: N
DENTAL: 1
WEIGHT: 3.8
TEMP: 38.6
BODY: 5