C10025846 / invoice 10000

History:- Presented for a recheck blood test and urinalysis.
- Chronic medical history includes inflammatory bowel disease (IBD), back pain, and anxiety.
- Current medications: pregabalin and prednisolone.
- Owner reports persistent polydipsia, which was present prior to starting prednisolone.
- Owner notes some behavioural changes, such as lying on the keyboard.
- Owner reports occasional wheezing sounds, especially in the morning.
- Recently assessed by a veterinary ophthalmologist (Dr. Yvette Crowe) who found no evidence of hypertensive retinopathy and only minor age-related changes.

Physical Examination:
Normal if not stated
- Weight: 3.43 kg.
Eyes:
- Ophthalmoscopic examination performed.
- Retinas appear normal bilaterally; no hemorrhages noted.
- Tapetum and optic disc appear normal.
- Menace response is present.
Abdominal palpation:
- A very full urinary bladder was palpated.
Limbs and gait:
- No back pain elicited on palpation today.
Cardivascular system:
- Blood pressure at ophthalmologist was 154 mmHg (systolic).
- Home blood pressure monitoring has shown variable results with some high outliers but also many normal readings.
Respiratory system:
- Lungs are clear on auscultation with only a very subtle wheeze noted on deep inspiration.
- No crackles detected.

Other Relevant Clinical Findings and Pathology Testing:
- Blood sample collected via jugular venipuncture for external laboratory analysis (biochemistry).
- Focus is on assessing hydration, renal parameters (urea, creatinine), and potassium levels.
- Urine sample collected via cystocentesis.
- In-house urinalysis revealed a urine specific gravity (USG) of 1.019.

Assessment/Summary:
- 14-year-old DSH with multiple chronic conditions.
- The primary concerns are the ongoing polydipsia and hyposthenuria (USG 1.019).
- Differential diagnoses for the low USG include prednisolone administration, early chronic kidney disease (CKD), or psychogenic polydipsia.
- Based on current IRIS guidelines and previous creatinine results, the patient does not currently meet the criteria for staging of CKD.
- Previous bloodwork showed low potassium, which will be re-evaluated.
- Ocular health appears good with no signs of systemic hypertension.
- Respiratory signs are clinically very mild.

Plan and Treatments:
- Submit blood sample to the external lab for biochemistry panel.
- Continue current medications as prescribed.
- The veterinarian will follow up with the owner via phone once results are available.

Need for a recheck and if so, when?
- A phone consultation is scheduled for tomorrow morning (March 14, 2026) to discuss blood results.

DH