C10004034 / invoice 10000

Appointment Notes: Urinating blood- next available appt - no preferred vet - When to doggy day care and they mentioned she was urinating blood. Had an ultrasound with us on friday.HISTORY:Doing well: Eating, drinking and toileting normallyCurrent Medications: No - But currently on weight loss planMedical conditions: Yes - Recessed vulva, dilute urine, polydipsia/polyuria - currently being workup up for potential hyperA.Vomiting or diarrhoea: NoAny Concerns: Yes - Urinated in house, frequent urination on walks, haematuria noted acutely this morning at doggy day care.Diet: Weight loss dietAppetite and thirst: Normal appetite, same thirst as previousOther relevant history: Recent ultrasound performed (bladder wall evaluated - no stones or structural abnormalities detected). Previous urinalysis last week showed no urinary infection. Symptoms developed rapidly within 24 hours.No known trauma, no access to rat bait.EXAMINATION: Demeanour: BAR MM: Pink, moist, CRT <2 Eyes: Clean and clear, normal eyelids, no erythema or discharge.Ears: Minimal debris, no inflammation or odour.Lymph nodes: Peripheral lymph nodes palpably normal Oral: No oral lesions or abnormalities detected.Teeth: Not assessed todayCardiovascular: Normal heart sounds, no murmurs or arrhythmias detected, femoral pulses synchronous and normodynamic.Respiratory: No nasal discharge, normal bronchovesicular lung sounds in all 4 quadrants, no coughing seen.Abdomen: Mild tense on caudal abdominal palpation. Pot bellied.MSK: Normal gait no lameness. Normal ROM with no pain of all limbs. No pain on DV palpation of spine.Integument: Coat is soft and clean, no ectoparasites detected, no obvious skin lesions or masses.Neurological: Normal mentation, no ataxia or CP deficits observed. Full exam not performed.Reproductive/Urogenital: Recessed vulva with deep skin folds, moist and slightly discoloured.Rectal: Not performedPROBLEM LIST:- Urinary tract infection- Recessed vulva- Dilute urine- Polydipsia/polyuria- OverweightDIAGNOSTICS:Inhouse Urinalysis:Sample collected FREE CATCH on arrival to the clinicUSG: 1.022LEU: 3+pH: 6.0PRO: 3+GLU: negKET: negBIL: negUBG: normERY: 4+Hb: 4+Cytology :haematuria, WBCs, purulent discharge cells, abundant bacteria (rod-shaped, in chains/clusters and intracellular), no crystals or renal casts detectedRecent ultrasound: No bladder stones or structural abnormalitiesASSESSMENT:UTI secondary to multiple risk factors including recessed vulva, dilute urine, and polydipsia/polyuria. Abundant rod-shaped bacteria noted on urine cytology with neutrophils. No structural bladder abnormalities on recent ultrasound. Weight loss plan already in place to help address recessed vulva. Patient comfortable, no systemic signs. Clinical improvement expected within 2 days of antibiotic therapy.MEDICATIONS:Amoxyclav 20mg/kg PO BID 7dPLAN:- Continue current weight loss diet to help reduce recessed vulva- Start antibiotics today - Rest for today, no strenuous exercise- Encourage water intake- Recheck urinalysis 5 days after completion of antibiotic course - for planned UCCR, but also potential reassess for infection and send for culture if required.- Consider urine culture if infection not clearing- Monitor for clinical improvement within 2 days- Return if signs worsen or no improvement noted    Vital Signs