C10004586 / invoice 10000

Appointment Notes: Dropping off for 10AM appt with GB CH 09/03History:She is straining to urinate a lot. Has been dropping 20c pieced of urine for the last few days. The las two samples have been clear. Last dose was a few weeks.Eating and drinking. Current diet consists tins of felix pouches and some fish.O thinks she is defecating normally.No current medication. once two or three years ago.  Examination:BAR,  mentation normalBCS: 5/9TEMP:    38.4        MM: pink, moist              CRT:  <2               HR:   184           RR: 16CVS: Normal cardiac rate & rhythm on auscultation. No murmurs detected. Pulses strong & regular.RESP: eupneic, normal effort, normal bronchovesicular sounds on auscultation of both lung fields. No nasal discharge ORAL: Grade 2/4  dental disease, maxillary premolard worst effected with localised gingivitis. Normal occlusion and no masses detected OCULAR: normal in size, no ocular discharge, no corneal or lens opacity EARS: NADLNs: submandibular, prescapular & popliteal LNs are consistent in size and consistencyGIT: Abdomen soft and palpable. No focal point of pain. No organomegaly appreciated.  M/SKEL: Ambulatory in all 4 limbs, well-muscled. No lameness detected. INTEG: area of alopecia on the nasal planum with some scabs present Skin is clear and intact. No skin tenting present.RECTAL EXAM: Not indicatedURINARY: NAD NEURO: Full exam not performed. Normal mentation. U/S: moderate thickening of the urothelium, trigone area appears ok. flocculent material within the bladder lumen3ml urine obtained via cystocentesis. Sent off to uni for full urinalysis, C and S.Rads: no evidence of bladder stones presentTreatment: Meloxicam 0.36ml into the mouth ONCE daily for a 5 daysO tro start on feliwayPlan: GB will call with interim with the results and if any further meds are needed.likely stress cystitis, spoke about reducing stress in the householdrecommended a dental in the next few months when urinary issues under control    Vital Signs