C10018112 / invoice 10000

MM -bloods + bp

Reason for presentation:(Bloods+BP-if checkng T4-please send to WAVES)

SUBJECTIVE/HISTORY:
  Behaviour: FAS (relaxed/mild) 
      Strategy (protective/avoidant) 
      Exited carrier (Y) Treats offered (Y) Treats taken (Y) 
      Handling techniques/preferences (blood draw challenging, does not respond well to more restraint) 
  Appetite: (normal) 
  Water Intake: (normal) 
  Urination: (normal)
  Vomiting history: Vomited yesterday 
Will bring up some grass 2x month.
 
  Coughing: (no coughing)
  Sneezing: (no sneezing)
  Faeces: not seen, goes outside 
  Current diet: Commercial wet and dry
  Current Medications: Amlodipine 0.625mg PO SID (Pre-visit medications: none)             
  Vaccination Status:  (UTD)
  Most recent endo/ectoparasite treatment: ()
  Housing:unsupervised access outdoors)
  Other animals in household: (none)

OBJECTIVE/ EXAMINATION:
Temperature: Not assesed
Mentation (BAR) BCS: 4/9   MCS: (2/3)
Hydration: (No evidence of dehydration)
Mucous membranes pink and moist, CRT <2 sec
Dental/oral cavity: (Mild calculus nad gingivitis in remaining teeth)
Nose/throat: (No significant findings)
Thyroid palpation: (normal, no goitre palpated) 
Eyes: No blepharospasm, no ocular discharges, fundic exam (NAD), full ophthalmologic exam not performed
Ears: No significant findings, clean. Otoscopic examination not performed. 
HR: (160) bpm, normal rhythm, no murmur detected, normal synchronous pulses
RR: (purring) bpm, regular, no significant findings on chest auscultation, normal effort
Abdominal palpation: No significant findings and comfortable on palpation
Urogenital: No significant findings, small bladder on palpation 
Integ: skin and coat healthy, no obvious lesions or lumps noted, normal skin recoil, red colouration obvious on RF and RH, O reports this has been there for last week, no obvious wound
Msk: no obvious limping noted
Peripheral LNs: No significant findings
Neurological: no abnormalities detected, a full neurological exam not performed
Feline grimace score if applicable (nil pain detected)

BLOOD PRESSURE MEASUREMENT
Position of cat (sternal). Location/room (consult)
Doppler, cuff size (2), location (tail)
Record of all SBP measurements (160,165,170,180,160)mmHg
Systolic BP (170)mmHg averaged over 5 readings 
Subjective assessment of stress (calm while eating creamy treat, very avoidant when not). Performed by (MM) 

ASSESSMENT/CURRENT PROBLEM LIST/DDx:
1. Weight loss
2. Poorly controlled hypertension

ONGOING PROBLEM LIST

1.Hyperthyroidism 
    I-131 therapy July 25
     
2. Hypertension 
- CKD vs idiopathic vs HyperT
- well managed 0.625mg PO SI amlodipine 

3. FIV positive subtype A

Previous Problems NOT CURRENTLY ACTIVE

1. Mandibular injury
- syymphyseal fracture - stabilised with suture placed 21/02/25
- 104 extracted to enable lingual frenulum wound to heal
- 303 fracture extracted
-402-403 severe periodontal injury - extracted
-404 CCF  - extracted

2. Tooth resorption
- Crown Amputation 204, 207 distal root, 304

3. HL muscle atrophy and pain - likely OA

4. Bacterial dermatitis
-responsive to cephalexin

PROGNOSIS
Guarded 

TREATMENT:
None in consult

PLAN:
MMto call with results from biochem of TAHP
if TT4 wnl then would need to r/o proteinuria and intra-abdominal disease (abdo US)

MEDICATION PLAN: 
Commenced:
Continue: Amlodipine 0.625mg PO SID