C10032891 / invoice 10000

Reason: Incontinent. CMVet: FMHistory:Previous history of urinary tract infections. History of intermittent diarrhoea associated with food sensitivities, currently managed on hypoallergenic diet (Royal Canin). Presented for urinary leakage/incontinence noted at home.Objective:BAR, hydratedTemp 38.2°CHR WNL, strong pulsesMM pink, CRT <2 secNo abdominal pain on palpationNo obvious vulval discharge noted at examAssessment:Urinary incontinence vs urinary tract infectionDifferentials discussed:Bacterial cystitisHormone-responsive urinary incontinence (common in desexed females)Less likely urolithiasis / bladder disease at this stagePlan / Treatment:Urinalysis recommended but declined at this time due to difficulty obtaining sample and wait timeTrial antibiotic therapy commencedContinue hypoallergenic dietMonitor response to treatmentIf no improvement, recommend urinalysis +/- urine culture and further investigationConsider trial therapy for urinary incontinence (oestrogen / phenylpropanolamine) if infection ruled outClient communication:Discussed two main possible causes of urinary leakage: urinary tract infection vs hormone-related incontinence.Explained that urinalysis is ideal prior to antibiotics but owner elected empirical treatment.Discussed risk of antibiotic resistance and possibility that signs may not improve if infection not present.Advised follow-up with local veterinarian if signs persist.Owner understands and agrees with plan.    Vital Signs    Weight: 28.4;