C10001481 / invoice 10000

RReason/concerns:  recheck post antibiotics for uti

History: eduf normal, no accidents, seems to be her normal self again. 

Pre-exisitng Conditions / Medications:
- No pre-exisitng conditions noted at the time of examination
- No medications currently being provided at the time of examination

Preventative Healthcare: Vaccination and parasite (flea, intestinal worms, heartworm). utd

Examine: 
Mentation: BAR
BCS:                3           /5   
MM: Pink     and moist     
CRT: 1-2 seconds
HR:      100                       beats/min
RR:            20                 breaths/min
Temperature: nt             degrees Celsius

Ocular: No abnormalities noted on cursory examination of both eyes.
Oral/Dental stage: Some gingivitis and calculus observed.
Ears: No abnormalities noted on cursory examination of both ears.
Cardiovascular: No audible murmur or arrhythmia and no difficulty hearing the heart. HR = PR and no evidence of hypoperfusion.
Respiratory: Respiratory rate and effort considered normal for the patient.
Gastrointestinal: No pain on abdominal palpation. No masses or abnormalities palpated.
Integumentary: No significant abnormalities.
Musculoskeletal: Normal gait and strength noted. No evidence of lameness.
Urogenital: No significant abnormalities noted during routine physical examination. No wetness or changes around vulva
Neurological: No evidence of neurological impairment or altered mentation. Detailed neurological examination not performed today.
Lymph nodes: Within normal limits for mandibular, prescapular and popliteal examination.

Lab: sedivue shows uti resolved, reduced rbc/wbc and no bacteria evident, pH improved, usg good. 

Patient Assessment: uti resolved, no indication of incontinance

Diagnostics performed (i.e. bloods, radiographs/ultrasound, ear cytology, urinalysis):
- sedivue as above 

Client Communication
& Plan: monitor, especially for any wet patches on bed. 

On-going medications required: Y/N (use prescription tab for further supply): n

Next check up date: as needed

Reason:  Check urine - rod UTI

History: Suddenly last night running out straining to urinate multiple times, panting and squatting and panting and restless - lasted for a large amount of night   
O collected first morning sample this morning 
Has urinated less today 
Last night was licking perineum a lot and today much less 

Current medications: none

What Preventative health cover is being used and do you need to purchase any today?
?

Examine: 
Mentation: BAR, lovely girl 
Body condition score: 5/9
MM: pink, moist               CRT: <2s
HR: 120               RR: 20
LN: all WNL
Temperature: NT

Ocular: NAD
Oral/Dental stage:  1
Ears: NAD
Cardiovascular: NAD 
Respiratory: NAD
Gastrointestinal: NAD
Integumentary & lumps (measurement, location): NAD
Musculoskeletal: NAD
Urogenital: small bladder, no obvious pain, recessed vulva but no perivulvular dermatitis and no obvious FB or other changes to vulva  
Neurological: NAD

Assessment: 
Urinalysis - large number WBC and rods present
- suspect UTI 

Treatment: start clavulox course 5d
carprofen BID 7d

Plan: Recheck urine 3 days after last dose AB - vet RV and urinalysis
O aware cystocentesis and C&S indicated if not clearing 

Ongoing Prescription required: N