C10026443 / invoice 10000

History:
BIB male O
Unsure of what RRR has been since last visit- wife counts this- does not think it has increased
Back on full dose of cardisure 0.625mg PO BID
Seems to be a bit improved- more lively than before
EDUD ok
O reports that still sneezing/ possibly coughing mildly at home but unchanged from last visit
O reports that at night sometimes to be breathing deeply- does not think is breathing more rapidly

Exam:
BAR
BCS 3/5
Oral exam mild tartar
MM's pink moist and CRT <2s
Ears ok
Nose ok
Eyes WNL
Thoracic auscultation grade 6/6 L sided heart murmur, lung fields clear
Abdo palp. ok, mild pot belly
LN's WNL
Skin moderate thinning fur coat
MSK- ok

Assessment:
High suspicion for cushings- elevated cortisol in urine and CS match
MMVD well managed- grade B2 but danger of deteriorating further
Cough ddx- non-cardiac dz (tracheal collapse, dynamic airway dz, bronchitis), cardiac dz decompensating (pulmonary edema)

Plan:
O to report back in next 1-2 weeks regarding RRR and monitor closely
Strongly recommend ACTH stim- O declined- advised O that w/o diagnosing + potentially managing cushings then becomes hard to interpret other symptoms and will lead to further organ damage and discomfort
Recommend continue pimobendan at current doses and recheck in 2mo for repeat echo and chest rads
Recommend recheck asap if deteriorates or RRR consistently >34bpm - can consider medication trial at this stage (frusemide or bronchodilator) 
Recommended booster beransa today- O declined

stoop to disc high UCCR suspicious of HAC so adv ACTH testing. o keen.
is currently on reduced dose pimo due to GI signs but or doing vmb in self already. plan to wean up to correct dose.
disc options for ACTH stim at cario rex, o to think & call back to book in.

Reason: 
Follow up call done by: LSC
History:
Recovery from GA/Sx/Dental: 
Eating: yes
Drinking:yes
Defecating:yes
Urinating:yes
Medications: giving cardisure as per label 
Advice to Owner: 
R / R / R: recheck in a month client will call back he dropped urine sample in to trinity gardens today LSC