C10010905 / invoice 10000

HISTORY: Been well. No issues noted at home. Eating and drinking well. Did have sedation (gabapentin) 1.5 hours ago. 

Current medications: Nothing other than gabapentin. 
Diet: Mixing some normal kibble with the grain free whilst uses up. 
Parasite control:

EXAMINATION:
HR: 124 =FP Subtle arrythmia today only-? sinus. CE listened, did not sound as it did when in previously. 
MM: pink   CRT< 2 secs
Temp:
Resp rate: 24
Body condition score: 5 /9
Muscle condition score: normal
Dental grade: 0 /4
Abdominal palpation:
Other:

ASSESSMENT: Taken ECG stills and videos on the 3 leads to send to Richard. 

PLAN/DISCHARGE: Await feedback from Richard. 

C5 
HISTORY: good no issues. healed since his leg issue but jumps down from the couch and overexcited it may irritate him a bit. 
EDDU normally
No v/d/c/s. 
Diet: scratch kibble + boiled blanched veggies 
Current medications: none
Parasite control: simparico trio + wormer 

EXAM:
BAR - friendly 
MM pink and moist, CRT <2s, 
Teeth good , dental grade  0/4
Eyes, ears, nose NAD
Hydration good
HR 144 , irregularly irregular heart sounds. have normal sinus arrythmia then switches to sporadic heart soounds, then back to normal., normokinetic and synchronous femoral pulses
RR sniffing and panting , lungs clear, normal effort
Peripheral LNs WNLs 
Comfortable on abdominal palpation, 
BCS 4 /9
Temp not taken
MSK – nad
Integument – nad
Neuro - nad

ASSESSMENT:
Problem list
1. irregular heart auscultation
1. recheck next week with ECG assessment, send ECG to Dr. R. Wooly  
2. referral straight to Dr. R. Wooly
O elected for option 1

TREATMENT: C5

PLAN: recheck heart in one week
gabapentin 100mg before next appointment 

DISCHARGE: 
We saw Sachi today for his annual vaccines. He did very well and wont be due for another year. 

We did notice that his heart does have an abnormality to it. This may be benign (not an issue) or something that we should further investigate. We would like to see Sachi in one or two weeks to reassess his heart. We will send him home with some medication to help him relax at his next visit for us to have a good listen to his heart. If the arrythmia is still present, we will admit him for an ECG. We will send the ECG recording to the cardio specialist for a second opinion and he may recommend you make an appointment to see him.

Grain free diets and heart disease have been linked. The exact cause is unknown and is still being investigated, however we do like to proceed with caution.

In the meantime, Sachi is free to live his normal life. 

 If you have any concerns or queries please do not hesitate to contact the clinic