C10031197 / invoice 10000

Reason: FLUTDHospital Time Period: History:Subjective:Objective:Temp:   37.7         MM:   pink           CRT:    <2         HR:   180          FP:   SSP           RR: 40BCS:    5/9                Wgt:  6.02  kg Pain Score (CSU):  2 /4CV:   gr2 murmur, irregular arrhythmia notedBPS RESP: no audible crackles or wheezes, normal resp rate and effort           GIT:  comfortable on abdo palp U/G: Moderately sized urinary bladder, painful to palpate, unable to express Neuro: QAR M/S: Ambulatory, comfortable on ROM of jts Integ: no visible petechiae or ecchymoses Ophth: NAD LNs: Nil peripheral lymphadenopathy. INTERNAL LABORATORYPCV/TS:	Blood Gases:pH PCO2 HCO3 BE cSO2Electrolytes:Na+K     Cl   Glucose  LactateIonised CaUreaCrea CBCAbnormal parameters:Blood smear examination:BiochemistryAbnormal parameters:UrinalysisCollection method: cystocentesis/urinary catheter/free catchpH:   Protein:   Glucose:   Ketones:   Urobilinogen:   Bil:   Ery:   Hb:USG:Sediment examination:EXTERNAL LABORATORY  Lab No: 	***pending ***Sample: Interpretation:IMAGINGAFAST:TFAST:Radiography:Problem List:Assessment: Treatment:Plan: Diagnostic plan :Therapeutic plan :Discharge plan :Referral plan :Client Communication:Financial Update:Options Offered to Client for Ongoing Care:Reason: DysuriaConsultation Time: History: BIOP DietIndoor vs outdoorCompanion catsNumber of litter traysRecent change in weight Recent change in thirstSubjective: QAR Objective: Temp     MM pink, moist   CRT  <2s    HR     FP BCS:   7/9                       Wt:   kgPain Score (CSU):   0/4CV:  nil murmur/arrhythmia, FP=HR, readily palpable bilaterally, hydration parameters WNL.        RESP:   NAD           RR and effort normal. GIT:   Abdominal palpation unremarkable, relaxed, non painful. U/G:  Kidneys WNL size, smooth, symmetrical, non painful. Urinary bladder xxxxxNeuro:  Mentation appropriateM/S:  Integ:  NADOphth:  Pupils mid sized, symmetrical. LNs: Nil peripheral lymphadenopathyProblem List:PollakiuriaStranguriaHaematuriaAssessment: Signs consistent with FLUTD-ddx FIC, urolithiasis, infection, inflammatory, neoplasia (unlikely)-non obstructed but risk of this at any stageDiscussed assessment as above, options offered:Recommend outpatient rx with a view to collect urine sample and revisit with RV in next 48h O indicated comfortable with this > recommend careful supervision, discussed signs which might indicate urethral obstruction warranting urgent intervention (persistence or worsening of current signs, stranguria with nil urine passed, pain/distress)Treatment:Buprenorphine 0.015mg/kg SCBuprenorphine 0.015mg/kg buccal BIDPrazosin/Dantrolene 0.5/6.25mg PO BIDCollect urine sample immediately prior to revisit with RV, specimen jar provided>Catrine litter beads providedPlan:Rx as aboveMonitor carefully for deterioration/signs suggesting urethral obstructionRecheck ASAP if any concerns============================================DISCHARGE INFORMATIONFELINE LOWER URINARY TRACT DISEASE (FLUTD)    Vital Signs