C09980379 / invoice 10000

BLDRQ: N
CLIN_EXAM: BAR, very sweet and gentle
Eyes: NAD
Ears: NAD
Oral: MMP, CRT <2s Dental grade 1/4- mild calculus caudal molars
CVS: HR WNL, no murmur detected, normal rhythm
Resp: RR WNL, normal effort, normal bronchovesicular sounds
Abdo palp: Small, comfortable bladder.
T: 38.4
BCS 6/9
Integument: Tip of penis purple in colouration
WRMRQ: N
FLRQ: N
TEMP: 38.2
WEIGHT: 5.9
HISTORY: See prev hx. Ongoing LUT signs. Recently seen at AVC- pyrexic (40) at the time. Bloods, UA and abdominal quick U/S and rads performed. Largely unremarkable. Awaiting urine culture results. 
Has been passing frequent small patches of urine the last 2 days. Seems uncomfortable and passing small drops/straining. Passed small volume on the sofa. Small volume red tinge present. 
Passed large soft stools the other day.
Fed urinary wet food with water supplementation. 
No current medications.
DIAG: 1. FLUTD with flare of C/S and obstruction of tip of penis
2. Pyrexia- resolved
TREATMENT: P: O agreed.
1. Flushed penis with sterile/lubed 24G catheter tip to remove obstruction- normal colour returned
2. Recommend recommencing analgesia: commence Meloxicam PO SID (normal renal parameters) and buprenorphine (prev dispensed) 
3. Discussed FLUTD resources- continue wet urinary diet and water intake
4. Phone call in 1-2 days
5. Continue monitoring for obstuction
6. Awaiting urine C+S results from AVC. Discussed performing abdominal spec U/S as recommended by AVC if not responding to treatment as expected

BLDRQ: N
CLIN_EXAM: BAR, very sweet and gentle, loves scratches
Eyes: NAD
Ears: NAD
Oral: Dental grade 1/4- mild calculus caudal molars
CVS: HR WNL, no murmur detected, normal rhythm
Resp: RR WNL, normal effort, normal bronchovesicular sounds 
Abdo palp: Moderate bladder- comfortable on palpation.
T: N/A
BCS 6/9
Integument: WNL
WRMRQ: N
FLRQ: N
WEIGHT: 6
HISTORY: Revisit today following episode of LUT signs 1 month ago. 
O started on RC urinary care diet after visit- likes this food. Currently feeding wet with water supplementation. 
Improved after initial visit but o reports LUT signs last week. Small volume blood-tinge present on bedding. No straining or frequent urination. Behaviourally normal. 
Also O/D for vaccinations.
DIAG: 1. Hx of LUT signs/FLUTD- controlled
TREATMENT: P: O agreed.
1. Urine sample collected via cystocentesis for urinalysis. Well concentrated with pH 7 and inactive sediment. No crystals or signs of LUT inflammation.
2. Recommend continuing current treatment plan. Continue urinary care diet long term to prevent recurrence, increase water intake, encourage activity, maintain lean BCS etc. Also discussed stress reduction etc. FLUTD handout provided to owners.
3. F3 administered S/C. Next booster due in 12 months' time.

NOTES: Called to check in. 
No accidents since yesterday. Owner is unable track how much he is urinating.
Owner is feeding wet only. Owner asked how much to feed. looked up the amount to feed RC website said for sachets a day.