C10004032 / invoice 10000

Appointment Notes: vacc. + repeat bloods + UA kl  ------- Sms reply: YHISTORY: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: Presented for an annual check-up, F3 vaccination, Zydax injection, and Ketamine top-up. Owner requests a re-evaluation of a suspected early-stage Chronic Kidney Disease (CKD) diagnosis and a script for Gabapentin. Patient has been more active recently. Owner reports a recent episode of excessive sedation following a home Ketamine injection.CURRENT MEDICATIONS: Ketamine (home injections), Amantadine, Meloxicam.PREEXISTING CONDITIONS: Suspected early-stage Chronic Kidney Disease (diagnosis under review). Presumed osteoarthritis.CURRENT DIET: Wet food. Previously on a prescription kidney diet.PE:- T-N- HR 144 bpm- RR/lungs:- MM-- LNN-- ABD- Tense, resistant to palpation.- BCS 4.7 kg body weight.- Otoscopy/ears:- Oral health:- Eyes:- Msk system:- Integument:- Urogenital: Not routinely examined.- CNS: Not routinely examined.Lab:Historical results:- 1 month prior: Urea 6.2, Creatinine 127, SDMA 13 (all WNL).- 2 months prior: Urea 7.2.- Previous diagnosis based on a single borderline USG and slightly elevated SDMA.PROBLEM LIST:1. Suspected Chronic Kidney Disease (under review).2. Chronic pain secondary to presumed osteoarthritis.Dx:DDx:Assessment:The patient is clinically well. Recent bloods show normal renal parameters. The diagnosis of early-stage CKD is questionable, based on a single borderline USG result, and requires re-evaluation with further urinalysis.Rx:1. F3 Vaccination administered.2. Zydax 0.14 mL SC administered.3. Ketamine 0.05 mL SC administered.4. Gabapentin 50 mg tablets. Dispense 100. Sig: 1 tablet PO BID.PLAN:1. Owner to collect a urine sample for Urine Specific Gravity (USG) analysis to re-evaluate renal function.2. If USG is normal, transition off the renal diet.3. Continue multimodal pain relief (Meloxicam, Amantadine, Ketamine) and commence Gabapentin.4. Advised owner on Ketamine injection technique (administer between shoulder blades).5. Advised owner to source Amantadine online to reduce cost.?????    Vital Signs    Weight: 4.7;       MMColour: Pink;       HeartRate: 144;       BodyScore: 5;       CRT: 1-2;