C09987299 / invoice 10000

Appointment Notes: Recheck spey and antibiotics. PVH   ------- Sms reply: YesAppointment Notes: Recheck spey and antibiotics. PVH   ------- Sms reply: Yes????History:The owner presented Bobbi due to a transient pale tongue yesterday, which resolved after eating. Today, she is lethargic, struggling to rise, and making "humps" sounds on exertion. A few days ago, she had a sore spot after jumping from a couch. Yesterday, after an accidental overdose of antibiotics (two whole tablets instead of two half tablets), she became hot and started breathing hard. Urination has not been observed as the owner has kept her inside to protect her surgical site. No vomiting or diarrhoea reported.- Significant history: Recent abdominal surgery.- Current medications: Antibiotic - 1/2 tablet - twice daily, Panadol, Metacam.- Appetite & diet: Appetite is normal, though she has not eaten this morning.Examination:Vital Signs: QAR, Temp 40.0°C, HR WNL, RR WNL, MM pink, CRT <2sec, Skin tent WNL- Eyes: No blepharospasm, no conjunctival hyperaemia, no epiphora.- Ears: Ears clean, no malodour.- Oral: Grade 0 dental disease.- Nose: NAD.- Cardiovascular: No murmurs or arrhythmias.- Respiratory: Clear bronchovesicular sounds on all lung fields.- Skin: Surgical incision healing well, no erythema or discharge.- Abdomen: Soft, non-painful on palpation, including around the surgical incision.- MSK: Reluctant to rise, vocalises with effort. Appears uncomfortable.- Lymph nodes: Submandibular, pre-scapular and popliteal LNs WNL.- Urinary/Genital/Rectal: Not assessedAssessment:Problem List:- Pyrexia (40.0°C)- Lethargy- Musculoskeletal pain/discomfort- History of recent surgeryTreatment:- Intravenous (IV) fluids initiated.- Additional injectable pain relief administered.Plan:- Admit for hospitalisation, IV fluid therapy and monitoring.- Collect blood for complete blood count and biochemistry.- Collect urine for urinalysis.- Veterinarian to call owner with diagnostic results.- Consider abdominal ultrasound depending on results (would require referral).- Continue antibiotics at the correct dose.- Tentative discharge planned for 5:50 pm.Client Communications:Discussed patient's pyrexia and the diagnostic plan to investigate the cause, including blood and urine tests. Potential differentials including post-operative pain or a urinary tract infection were mentioned. Owner consented to hospitalisation and diagnostics, with an estimate of $700 provided. The correct antibiotic dosage was reiterated. Advised that an ultrasound may be recommended pending initial results. Owner to be contacted with results later today.11:00 Called O w/bloods, UA and xray results - Recheck CBC and temp tomorrow. ??????????History:A 15-year-old, female desexed cat presented for periuria (urinating on couches). This is an intermittent issue. The owner reports a history of urinary tract infections some time ago. Appetite, diet, and water intake are normal. The patient has occasional hairball vomiting but no coughing or sneezing. The patient had a recent spay surgery. The owner believes she is otherwise healthy.- Significant history: Previous urinary tract infections. Recent spay surgery.- Current medications: Metacam (last dose yesterday morning), Panadol (twice daily).- Appetite & diet: Appetite is normal. Fed a urinary-specific diet.Examination:Vital Signs: BAR, HR WNL, RR WNL, Temp 38.5°C (fluctuated during the day, responsive to analgesia), MM pink, CRT &lt;2sec, Skin tent WNL- Eyes: No blepharospasm, no conjunctival hyperemia, no epiphora.- Ears: Ears clean, no malodour.- Oral: Grade 0 dental disease.- Nose: NAD.- Cardiovascular: No murmurs or arrhythmias.- Respiratory: Clear bronchovesicular sounds on all lung fields.- Skin: Normal coat, no ectoparasites.- Abdomen: Soft, non-painful. No masses palpated. Kidneys normal size and shape.- MSK: Mild generalised joint stiffness. Spinal radiographs NAD. Ambulating normally.- Lymph nodes: Submandibular, pre-scapular and popliteal LNs WNL.- Urinary/Genital/Rectal: Not assessedAssessment:Problem List:- Periuria- Pyrexia, pain-responsive- R/O Urinary Tract Infection- R/O Ovarian remnant infection / stump pyometra- Mild osteoarthritisTreatment:- IV antibiotics administered in clinic.- Methadone injection administered in clinic for analgesia.- Bloods collected for analysis.- Spinal radiographs performed.Plan:- Dispense Amoxiclav antibiotic course. Administer first dose tonight.- Continue Metacam as previously directed (next dose tomorrow night).- Continue Panadol twice daily.- Dispensed urine collection kit. Owner to collect a free-catch urine sample and return within 12 hours for urinalysis.- Recheck appointment with a nurse tomorrow at 8:10 am for a temperature check.- If no improvement overnight, an abdominal ultrasound will be recommended (requires referral).Client Communications:- Discussed differential diagnoses for clinical signs, primarily UTI vs. ovarian remnant infection.- Explained prognosis is dependent on the underlying cause. A UTI may require a 2-week antibiotic course, while an ovarian remnant infection may require surgery.- Advised that blood results will be communicated tomorrow.- Instructed on medication administration and urine sample collection.- Recommended home temperature monitoring.- Advised against further vaccinations due to age.?????    Vital Signs    Temperature: 40;       

Appointment Notes: TPRPresented for recheck following pyrexia 3 days (see hx)Started on panadol yesterday O reports still more quiet than usual, eating and drinking ok. No D+/V+.Temp 39.6Offered bloods - O declined for now and opted to trial AB and recheck temp tomorrow. If temp worse or not improved bloods. Amoxyclav 200mg 1/2tab PO BID 10days. Continu metacam and panadol.     Vital Signs    Temperature: 39.6;       

Appointment Notes: 3 days POC Spay GW  ------- Sms reply: Yes3 day POC BAR 1 vomit 1 day post surgery. showing less interest in breakfast this morning.Wound looking good no signs of infection redness or swelling. looked irritated so showed MB. O concerned that Bobbi not responding to her name when called yesterday afternoon and this morning took temp at 39.5. MB spoke with them to come in for POC tomorrow and confirm if temp going down or may need to start on AB (AH)MB: NQR and moderate back pain - maybe sore back from lying on operating table, or injury in recent days. Slight pyrexia but otherwise very bright and happy. Start paracetamol 10mg/kg BID-TID and RV tomorrow AM for nurse TPR. If temp still high, consider bloods and US vs ABx trial      Vital Signs    MMColour: Pink;       RespirationRate: 24;       HeartRate: 120;       Temperature: 39.5;       BodyScore: 5;       CRT: 1-2;