C10005439 / invoice 10000

Record complete N

Reason/concerns: Urinary infection 

History:
O's parents brough kinder today. 
Stranguria noted. Small amount of urine. The last urination contained blood. 
Intermittent vomiting. Last vomit yesterday morning after food. No vomiting seen since then. 
Stool soft but formed. Polydipsic. 
O requested if stilboestrol dose can be increased. 

Medications:
Stilboestrol 1mg once weekly 

Preventative Healthcare: Vaccination and parasite (flea, intestinal worms, heartworm).

Examine: 
Mentation: BAR
BCS:  5/9 
MM: Pink, moist          
CRT:  <2 seconds
HR: 128 beats/min
RR: wnl        
Temperature:  38.2

Ocular: No abnormalities noted on cursory examination of both eyes.
Oral/Dental stage: G /4
Ears: No abnormalities noted on cursory examination of both ears.
Cardiovascular: No audible murmur or arrhythmia. Strong synchronous pulses. 
Respiratory: Respiratory rate and effort considered normal for the patient. Normal BVS
Gastrointestinal: No pain on abdominal palpation. No masses or abnormalities palpated.
Integumentary: No significant abnormalities.
Musculoskeletal: Normal gait and strength noted. No evidence of lameness.
Urogenital: No significant abnormalities noted during routine physical examination.
Neurological: No evidence of neurological impairment or altered mentation. Detailed neurological examination not performed today.
Lymph nodes: Within normal limits for mandibular, prescapular and popliteal examination.
Problem List:

Patient Assessment: 

Diagnostics performed:
1) Ultrasound guided cystocentesis:
-Extremely small bladder. Bladder wall appears to be normal. No obvious bladder stones/masses noted. 
-Small amount of urine collected for Full UA:

2) Full UA:
-Colour: Yellow 
-Inadequately concentrated urine - SG 1.028
-Bacteriuria in the present of pyuria 
-Haematuria
-Trace protein present in active urine sediment

3) Blood work - PreGA
-Pt escalated. Unable to collect today. 

Treatment:
Clavulox 250mg BID 7d
Paracetamol 100mg/ml 1.3mls BID 3-5d

Client Communication
& Plan: 
-Phoned Leanne with urine results. Bacteruria present, rods. Recommended urine culture and sensitivity. Estimate discussed and permission given to proceed. 
-Awaiting urine culture results. 
-Dispensed clavulox BID 7d while awaiting results. 
-RV for repeat blood work to monitor creatinine. The latter previously elevated with normally concentrated urine. 

Reason: Courtesy phone call 
Nurse: NP 
History: urine issues 
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