C09970558 / invoice 10000

Reason: Gagging ??Subjective: No prev history, no medsHas had a 2 day history of gagging/coughingEating less foodNo v+ Started licking the carpet / tiles, gagged a few timesNormal faeces thoughObjective: BAR nervous but lovely, mm pink, CRt 1 sec, HR 128, no murmur, pulses strong and synchronous, chest clear, RR 20, effort normal, abdo relaxed and NAD, T 39.1Submand LNs mildly up, tracheal pinch negative. Hard to examine intra-oral, resists opening, but from what can be seen looks unremarkable. Assessment: pharyngeal irritation, vs other (GI related, thoracic related)Plan: Metacam, monitor. If v+, worsening, inappetance continues, re-exHistory: GX client    Vital Signs    Weight: 7.5;