C10003726 / invoice 10000

HISTORY: History:
Not himself, feeling a little worse -O reports uncomfortable stomach 
Lives with another cat - they dont fight
Still eating. Defecated 2 days ago. No straining to urinate/defecate

Examination:
Behaviour: BAR , General Body Condition: good, BCS: 5/9
Temperature: 38.7.  
Cardiac auscultation : normal rate/rhythm, no murmurs, HR: WNL,  RR: WNL 
MM: pink, moist  CRT< 2 sec
Dental disease:  0/4            Oral exam: WNL , no Fb around tongue 
Nose: NAD
Eyes: NAD
Ears: NAD
LN: NAD            Abdo palpation: comfortable, large amt of hard feces in colon
Gait: NAD/no limp noted
Skin: NAD   Coat: Good condition

REPEAT BLOODWORK: all WNL, bilirubin WNL 

Assessment: 
constipation (primary vs secondary)
Other GIT cause - FB? other 

Treatment
micolax - defecated large amt of feces +++++
0.49 ml prevomax (SC) 
Home with clav drops BID 7 days 

Plan: if no improvement within 24 hrs advise ultrasouind
WRMRQ: N
FLRQ: N
WEIGHT: 4.9

HISTORY: Presenting: Been off lately and uncomfortable in belly

History: O noticed unusual behaviour the past 4 days, not as energetic and had a weird gait. Has not seen a poo in one day. Otherwise still has appetite and O says that drinking and peeing have been normal. Has not eaten anything unusual and there are no toxins in the house. 

Vomiting, diarrhoea, sneezing, coughing: None
Diet: R/C dry and wet
Other pets: Another cat at home, can distinguish the poo but not pee
Inside/Outside: Inside only 
Last vaccination: Not UTD
Last worming, fleas, ticks: worming tablet
Current medications: None 

Physical Exam:
Mentation: BAR
BCS: 6/9
Temp: 37, seemed to be something solid blocking the thermometer.
MM: Pink moist CRT <2s
Eyes: NAD, no discharge, no blepharospasm, no epiphora
Ears: NAD, no discharge, no odour, no redness/inflammation
Nose: NAD, no discharge
Oral: Grade 2 dental disease
Heart: HR 200, no murmurs/arrhythmias
Lungs: RR <30, no crackles, no wheezing
Lymph nodes: NAD
Integument: NAD
Abdomen: Comfortable with palpation
Musculoskeletal: ambulatory on all limbs, no lameness/swellings/weakness
Neurological: appropriate mentation, full neuro exam not performed
Urogenital: no discharge or swellings, big expressible bladder 
Rectal: Not performed 

Diagnostics:
Haematology and biochemistry:
Mild neutropaenia - likely stress
Mild thrombocytopaenia - likely artifactual
Mild hyperbilirubinaemia - cholestasis? liver disease?
Urinalysis: WNL

Assessment:
Unusual behaviour - ddx: constipated, FIC, acute liver disease/damage?, non-obstructive FB? 

Plan:
Give gabapentin 25mg BID for 10 days to treat possible FIC.
Give 1ml lactulose BID for 5 days, may increase to 2ml if P does not poo.
Monitor toileting, if no improvement then come back for repeat bloods. If starting to develop clinical signs like V+ and D+ or inappetence then require abdominal u/s (gave estimate).
WRMRQ: N
FLRQ: N
WEIGHT: 5

HISTORY: Clipped claws