C10001258 / invoice 10000

Appointment Notes: Not herself + lethargic MVKHISTORY:CURRENT DIET:PREEXISTING CONDITIONS: CURRENT MEDICATION: PE:T-HR/CARDIAC-RR/RESP-MM-CRT-LNN-ABD-BCS-OTOSCOPY/EARS: ORAL HEALTH: EYES: MSK: INTEGUMENT: UROGENITAL: CNS: Not routinely examinedPROBLEM LIST:DX:DDX:RX:PLAN:?????HISTORY: Acute onset lethargy, hypodipsia, and inappetence since this morning. Owner reports constipated stool and reduced urination today. History of osteoarthritis and a chronic, progressive cough. Previous foreign body ingestion four months prior, resolved.CURRENT MEDICATIONS: None reported.PREEXISTING CONDITIONS: Osteoarthritis (hips). Chronic cough.CURRENT DIET: Reports of overfeeding. Brand/type not specified.PE:- T-N 39.4°C- HR- RR/lungs:- MM-- LNN-- ABD- Comfortable on palpation. Possible slight cranial abdominal fullness.- BCS- Otoscopy/ears:- Oral health:- Eyes:- Msk system: Generalised discomfort on movement. Reluctance to walk.- Integument:- Urogenital: Not routinely examined.- CNS: Not routinely examined.Lab: Bloods submitted for Differential Haemogram Profile (DHP) and C-Reactive Protein (CRP). Urinalysis deferred. Previous bloods performed 4/12 ago, results unavailable.PROBLEM LIST:1. Pyrexia2. Lethargy3. Generalised pain/discomfort4. Hypodipsia5. Possible cranial abdominal fullnessDx: Pyrexia of unknown origin (PUO).DDx: Infection (e.g., UTI), inflammatory disease, neoplasia, pain-related pyrexia.Assessment: 14-year-old Labrador presenting with acute lethargy and pyrexia. Examination findings include generalised discomfort and possible cranial abdominal fullness. Primary differential is an infectious or inflammatory process.Rx: None at this stage.PLAN: Await blood results (DHP, CRP). Contact owner to discuss results and further plan. Consider symptomatic treatment with paracetamol if bloods are unremarkable. Further investigation may be required based on results.?????    Vital Signs    Weight: 35.3;