C09970276 / invoice 10000

Reason: Dry Reaching + Lip SmackingJLE: Regular vets = Adelaide VetHISTORY:  Presented for assessment of dry retching which commenced this morning. The owner is concerned about potential ingestion of a foreign object or substance.She passed normal faeces outside here today.no noted vomiting.No known access to toxins or rubbish.Current meds: noneVaccination: UTDParasite Prevention: monthly Simparica - due now.Pre-existing conditions: none knownAccess to toxins eg. Rodenticide: none EXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): not graded- Abdominal: no detectable pain on abdominal palpation. Borborgymi++- Rectal: normal faecal smear on gloved finger. emptied both anal sacs of normal secretion.Urinary: NSFReproductive: desexedIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: BAR PROBLEM LIST:Acute onset of dry retching and inappetence today. DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Gastrointestinal issue. Cannot rule out foreign body, pancreatitis, organ dysfunction. DIAGNOSTICS:None ASSESSMENT:  Presented for acute onset of dry retching this morning. Physical examination revealed no significant abnormalities. The primary concern is a gastrointestinal issue. TREATMENT:  Administered maropitant 1mg/kg s/c at 09:25am PLAN:Discussed differentials and the work up required (bloods, imaging). As Hiccup is still bright and stable, elect to treat symptomatically for today and return later for further diagnostics if any deterioration.Further diagnostics may be required if clinical signs persist or worsen.Home into owner's care (to feed little and often bland food today and return if any vomiting. CLIENT COMMUNICATION:Discussed the plan for admission and observation. The owner was advised on the potential need for further diagnostic tests if the retching does not resolve. The owner understands and consents to the plan.    Vital Signs    Weight: 5.5;       Temperature: 39;