C09980796 / invoice 10000

blood tinge in urine thismorning

Reason for presentation:

possible blood in urine

GAP ONLY CHECK LIST

*Reason for visit: possible haematuria

*Primary diagnosis/suspected diagnosis/location: unknown - no changes on UA today

*Suspect cause: possible genital tract involvement vs rectal vs anal sac

*Any other conditions being treated (if any): see hx

*Date of first clinical signs (if known): acute


SUBJECTIVE/ HISTORY:
  Behaviour: FAS (mild/moderate) 
      Strategy (inhibited - protective on abdominal palpation) 
      Exited carrier (lifted out) Treats offered (churu) Treats taken (none) 
      Handling techniques/preferences (gentle and slow, did very well for blood draw medial saphenous (butterfly 21G) while sitting on mum's lap with churru) 
  Appetite: (Hyporexia) Water Intake: (Normal) Urination: (Normal)
  Faeces: (Normal) Faecal score (2/7)
  Current diet: (Various foods including freeze-dried chicken, creamy treats, soft chicken tuna, and Fancy Feast kitten food (chicken flavor))
  Current Medications: 
     - Pregabalin (APO), 25mg caps, 1 (25mg) PO SID
     - Methimazole (Thyronorm), 5mg/ml, 4mg PO BID



  Vaccination status: LAPSED





OBJECTIVE/ EXAMINATION:
Temperature: Normal
Mentation (BAR) BCS: /9   MCS: (1/normal)
Hydration: (No evidence of dehydration)
Mucous membranes pink and moist, CRT <2 sec
Dental/oral cavity: ()
Nose/throat: (No significant findings)
Thyroid palpation: (normal, no goitre palpated) 
Eyes: No blepharospasm, no ocular discharges, fundic exam (), full ophthalmologic exam not performed
Ears: No significant findings, clean. Otoscopic examination not performed. 
HR: () bpm, normal rhythm, no murmur detected, normal synchronous pulses
RR: () 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
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)

LABORATORY:
CBC: ()
PCV/TP: ()
BIOCHEM: ()
BLOOD GAS ANALYSIS: (No significant abnormalities)
USG: ()

ASSESSMENT/PROBLEM LIST/DDx:




1. Acute pancreatitis - RESOLVED
     - Presenting with acute vomiting, hyporexia, abdominal pain, dehydration and diarrhoea
2. Weight loss - IMPROVING

ONGOING ASSESSMENT/PROBLEM LIST/DDx:
1. Hyperthyroidism - poorly controlled, very rapid increase in spikes
     - TT4 138 (APR 25) 
     - Improved to TT4 67 on thyronorm (MAY 25) then 11 (JUL 25), 17 (SEP 25)
     - Spike in TT4 to 120 when pancreatitis episode (OCT 25), increased further to 181 (DEC 25)
2. Moderate dental disease
3. Pigmented lesion medial right iris - MONITOR
4. No evidence of renal insifficiency on bloods while euthyroid
     - Creat 100, SDMA 9, USG 1.041, UPC 0.1 (JUN 25)

PREVIOUS PROBLEMS NOT CURRENTLY ACTIVE:
1. Hx anal sac abscess, treated at PVE (APR 25) 

PROGNOSIS:
Good - Fair 

TREATMENT:
None today

PLAN:





- Run TT4 today; phone owner with results.
- Dental: COHAT recommended in the new year; likely extraction of 208 discussed.




Previous:
- Borderline high BP with no evidence of hypertensive retinopathy, repeat in 3 months (with TT4) and consider tx if trending up.
- Discussed I131 therapy as a future option; owner to consider once settled in new job.
- Consider referral to ophthalmologist if iris lesion changes.

MEDICATION PLAN: 
Continue:
     - Pregabalin (APO), 25mg caps, 1 (25mg) PO SID
     - Methimazole (Thyronorm), 5mg/ml, 2.75mg mark (2.75mg) PO BID (prescribed) - as per WAVES, use 4mg PO BID