C09989195 / invoice 10000

Appointment Notes: Overdue reminders uti-tlHistory:Did a big vomit around lunch time yesterday, brought up her breakfast and some grass Noticed a small drop of blood on her floor, then noticed her wincing when she's urinating. Did it again this morning when she winced when peeing Ate normally today. Was a bit lethargic last night, this morning a bit more quiet than her normal self. Still active Examine: BCS: 6/9RR: pant HR: 104temp: 39.1Mentation: BAR Oral: C1G0 - bit hard to look well inside mouth as not tolerating oral exam as much Cardiovascular: mm pink and moist, CRT <2s. Normal rhythm, no obvious murmurs. SSFPResp: normal RR and effort clear lung sounds all field EENT: eyes, nares clear bilaterally, ears clear. Integ: skin clear LNs: peripheral LNs palpates normally Abdo: abdo palp unremarkable, nil pain on palpation MSK: ambulatory, normal gait Rectal: not performed Urogen: vulva bit hooded but not inflamed, nil dischargeNeuro: normal mentation, full neuro exam not performed Laboratory: Urinalysis - voided sample, urine brownish/yellow, slightly turbid USG 1.038 Dipstick - protein +, pH 8.5, large blood Sediment - nil crystals Smear - rbc ++, wbc ++, saw one cluster of rods Assessment: UTI Treatment: Amoxyclav 200mg 1 tab PO BID q14d Meloxicam 1mg 1.5 tab PO SID as required for pain Plan:Repeat urinalysis after antibiotic course Start meloxicam tonight, ensure no further vomiting before giving nsaids Monitor urination Rec further workup with bladder u/s under sedation + cysto for further urine testing ini    Vital Signs    Weight: 14.4;       Temperature: 39.1;