C09971269 / invoice 10000

REASON: 
Presented for recheck after visiting BVECCS last night. Had episode of increased resp effort, anxious, 1x diarrhoea (mucousy) and drooling/yellowy  foamy mouth with apparent upset GIT and flatulence.  Vet suspect potential aspiration after vomit and GIT upset. Vet prescribed amoxyclav 2 week course, and recommended a bland diet. O reports otherwise well today, not wanting to eat, faeces are soft "mr whippy" consistency. No other concerns at home.

HISTORY:

Other important medical Hx +/- current medications:
Vaccination status: UTD
Preventatives: UTD
Diet: Diet at home is raw fresh human grade choicken and beef and small handful of kibble. 

PHYSICAL EXAMINATION:
HR: 92
RR: 24
Temp.:38.6
BCS:6/9

CV: NAD, no murmurs, no arrhythmias, MM pink and moist, CRT <2secs 
RESP: normal respiratory effort and sounds
EENT: NAD, ears clear, eyes clear, nose clear, grade /4 DD 
PLN: NAD, submandibular, prescapular and popliteal LN's palpated as normal size 
ABDO: tense, no obvious masses, slight gas sounds
INTG: NAD, no lumps, no other skin lesions 
MSK: NAD on distant gait examination, able to rise and ambulate normally 
NEURO: NAD w/ normal mentation, complete neurological examination not performed
URO/REPRO: NAD, 

DIAGNOSTIC TESTS:
Full TAHP and CRP

PROBLEM LIST & ASSESSMENT
1. Potential aspiration after suspected vomit
2. GIT upset 

TREATMENT & PLAN 
1. Continue wit antibiotics, and bland diet
2. send b;loods to check for potential subclinical aspiration etc
3. prokolin for next 3-5 days or as neccessary
4. recheck monday if otherwise OK over weekend and not needing to be seen earlier.  

Dr. Amelia Fallon BVSc

Blood results: called O with bloods - CRP 31.7 - O is going to bring Jac back in for a recheck on Monday and would like CRP redone so can check is coming down. O good with that plan. AP