C10028965 / invoice 10000

Reason: abdo ultrasound  /rads to investigate weight loss and painPrev Lab results:Urea 11Creat 0.16Sdma 31Urine was dilute with trace proteinLast couple days has seemed improvedExamine: mms pink, terrible teethLean body condition, Sore lumbar spineHr 100, no murmurRr 24Abdo palpation - v tenseUltrasound: not sedated but was groaning when laid on her side so gave 0.3ml buprenorphine - helped her to settleLiver parenchyma normal appearance. Large square to round shadowing object in gall bladder-25mm - looks like a cholelith. Gall bladder mild-moderate sediment, no distension of common bile ductStomach - empty, mucosa 3.4mmSpleen rel large but normal appearanceLK - fluid accumulation in renal pelvis-up to 5.1. LK 38.1mmOverall shrunkenRK hard to image as deep under ribs but appears rel normal 40mmLeft adrenal normal 4.6mmUnable to see r adrenalSmall intestine 3.3/3.4Duodenum 3.8mmColon - formed faeces 1.7mm mucosaPancreas looks normalUrinary bladder v small - unable to get cysto sample - delay sending home and try again laterNo lymphadenopathy, no free fluidBlood pressure - normotensive 147/90Assessment: Fluid dilation left renal pelvis - poss pyelonephritis vs prior ureteral obstructionXrays:joints/spine all look rel normalNad thoraxNot seeing major mineralisation of kidneys/uretersPlan: Await urine c/sCont current pain killers, not excessively sedate on gabapentin    Vital Signs