C10001752 / invoice 10000

Reason: Not Urinating (No Straining), InappAppointment Notes: Overdue remindersHISTORY:Current meds:Prophylaxis:Pre-existing conditions:Access to toxins eg. Rodenticide:TRIAGE:HR:RR:Temp:Mm: Crt:Mentation:Pain Scale (0-4):Hydration status (%):EXAMINATION:Body Condition Score: Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4):  - Abdominal: no detectable pain on abdominal palpation, normal gut sounds- Rectal: no detectable abnormalities, faeces:  Urinary: NSFReproductive (incl ext genitalia): NSFIntegument/Ears: NSFLymph Nodes: peripheral lymph nodes normalEyes: NSFPROBLEM LIST:DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:DIAGNOSTIC/MANAGEMENT PLAN:DIAGNOSTICS:ASSESSMENT:TREATMENT:PLAN:CLIENT COMMUNICATION:------------------------------------------------------------------------**CLIENT DISCHARGE NOTES**PRESENTING CONCERNS:Raphael was presented for being very lethargic, reduced appetite, and not being seen to pass urine since last night.PROBLEM LIST FROM PHYSICAL EXAMINATION AND HISTORY:- Lethargy and decreased activity- Reduced appetite- Not observed urinating- History of urinary issues (FLUTD)- Recent stress from a dental procedureASSESSMENT:Raphael was examined and found to be stable. His bladder was small and comfortable, making a urinary blockage unlikely at this time. His signs are suspicious of a flare-up of non-obstructive Feline Lower Urinary Tract Disease (FLUTD), which can be triggered by stress. We have started him on medication to make him more comfortable and reduce inflammation.DIAGNOSTICS/MANAGEMENT:- A thorough physical examination was performed.- No diagnostic tests were performed in hospital today.- Medications have been dispensed for you to administer at home.PLAN:Please monitor Raphael very closely at home over the next 24-48 hours. It is important to watch for any straining to urinate, frequent trips to the litter tray with no result, or worsening lethargy. If you notice any of these signs, please return to an emergency centre immediately. We advise a follow-up appointment with your regular veterinarian within the next 48 hours to ensure he is improving.Medications for Administration at Home:- 3.70 x Buprenorphine Injection (S8)Give one Syringe (0.36mls) morning and night by mouth- may cause sedation- 10.00 x Gabapentin 100mg CapsulesOne (1) tablet twice a day, may cause sedation.SPECIFIC HOME CARE INSTRUCTIONS:The Animal Emergency Service advises a reassessment with your regular vet within 48 hours to monitor your pet's progress. If your pet's condition deteriorates or they become flat or lethargic, go off their food and water, develop vomiting or diarrhoea or if you have any concerns, please contact the Animal Emergency Service or your primary vet immediately.Thank you for trusting the Animal Emergency Service with the care of Raphael.    Vital Signs    

    Vital Signs    

Reason: EON ? - TREyes Overnight:- Patient status:Urinating around catheter @0400 - Clear urineUrinating small amounts in litter tray @0530- Medications administered: (drug, route, time)As prescribed- Fluid therapy:Maintenance hartmans- Interventions overnight:Removed Urinary Catheter as was urinating around itLPV STO @0430 asking permission to remove and than go home for continued monitoring - owner happy with the plan. Plan fo discharge in the am    Vital Signs