C10027216 / invoice 10000

Reason: L4 - Frequent Bloody UrineHISTORY:Queen Peach presented for pollakiuria and clots present in some urine puddles for 12 hours history. Still eating, but less enthusiastic.No other issues noted.Current meds: gabapentin, fluoxetine. Prophylaxis: UTDPre-existing conditions: hip dysplasia, anxietyAccess to toxins eg. Rodenticide: no knownTRIAGE:HR:  120RR: pantTemp: 38.7Mm:  PMCrt: <2sMentation: QARPain Scale (0-4):  1/4Hydration status (%): euhydratedEXAMINATION:Body Condition Score: 6/9Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4):  1- Abdominal: mild pain detected- Rectal: NPUrinary: NSFReproductive (incl ext genitalia): NSFIntegument/Ears: NSFLymph Nodes: peripheral lymph nodes normalEyes: NSFPROBLEM LIST:PollakiuriaPigmenturia1 rod found in UADIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:UTI vs crystal vs urolith vs idiopathic renal haemorrhage vs TCC vs coagulopathy vs otherDIAGNOSTICS:> Urinalysis in house (cystocentesis):- See attached results for full urinalysis- USG: 1.049- Colour: greenish yellow - pH: 5- Protein: 2+- Blood: 4+- Ketones: -- Glucose: -- Bil: - - Ubg: - - Wet Prep:  debris- Dry cytology: occa. RBC, WBC, 1 extracellular rodASSESSMENT:Patient presented with lower urinary signs, mild abdominal pain, no pyrexia. UA result either early UTI vs contamination in which case cause of signs not explained yet. Culture sending out. Results to guide next step. TREATMENT:Amoxyclav 250mg PO BIDParacetamol 250mg PO BID-TIDPLAN:Culture results pending to determine whether early UTI vs cause not identified, consider rads, bloods, etc.CLIENT COMMUNICATION:Discussed differentials, offered to start with UA, owner happy to proceed, updated owner on findings, discussed plan as above, owner happy with plan. DISCHARGE INSTRUCTIONSPlease read through the following instructions to help guide your pet’s recovery. Do not hesitate to contact us at any time if you have any concerns or questions, and please let your vet or our client care team know if you have any questions about this information before you take your pet home today. Treatment summary: Queen Peach presented today for frequent urination containing some blood clots. An in house urine test has found 1 single baciteria which suggest either an early infection or may be a contamination from the stain. She is to be started on empirical antibiotics while waiting for her urine culture. If the urine culture is negative, please recheck with your vet for further investigation. The result will come back in 3-5 days. Exercise:- NormalDiet:- Normal Recheck:- Please organise a recheck for your pet with your primary care veterinarian in 3-5 days, earlier if she is not eating, not improving or if you have other concerns. Medications at discharge:Amoxyclav 250mg One (1) tablet twice a day.Paracetamol 500mg (panadol) - to obtain from pharmacy, give half a tablet (250mg)every 8-12 hours as required for pain relief for 3-5 days. If your pet is going home and has a pressure wrap over where an IV catheter was placed please remove it within 20 minutes of leaving the hospital. If your pet’s condition is not improving or if other problems develop, please call your primary care veterinarian or if it is outside their normal working hours, please call Perth Vet Emergency.  We are open from 6pm until 8am Monday to Friday and 24h over weekends and public holidays. Phone 1300 040 400    Vital Signs    Weight: 16.1;       

External Laboratory Test Results-------------------------------------------------------------------Laboratory:    Novavet   /    VetpathTest type:Submission date:Report arrival date:Summary of results:Interpretation/Assessment:Plan:Client communication:Veterinarian:    Vital Signs