C09972010 / invoice 10000

HISTORY:- Presented for ingestion of an EM1 fruit enzyme extract (compost accelerator) approximately two hours prior to presentation. The dog is believed to have licked a small, jelly-like amount of the product, possibly from a banana peel, after the owner rinsed out a bin.- The dog is reported to be bright and energetic with no signs of gastrointestinal upset, drooling, or other symptoms of toxicity post-ingestion. No actual compost material was ingested. - no other known PECs- UTD prophylaxis- eddu normally- no other concernsPHYSICAL EXAM:TRIAGE:HR: 112 bpmRR: 40 brpmTemp: Not takenMm: MoistCrt: <2 secondsMentation: BARPain Scale (0-4): 0/4Hydration status (%): euEXAMINATION:Body Condition Score: 5/9Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score: 2/4- Abdominal: no detectable pain on abdominal palpation, normal gut sounds- Rectal: Not performed.Urinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: peripheral lymph nodes normalEyes: clear cornea, no blepharospasm, no redness, white sclera, no dischargePROBLEM LIST:1. Ingestion of EM1 fruit enzyme extract.DIFFERENTIALS:EMI fruit enzyme extractDIAGNOSTICS- Ingestion of AM1 enzyme fruit extract, a compost accelerator. No ingestion of actual compost.ASSESSMENT:- The ingestion of the enzyme extract is considered unlikely to cause any significant issues beyond potential mild gastroenteritis.TREATMENT:nilPLAN:- The owner was advised that the ingestion of this enzyme extract is unlikely to cause any significant toxicity and the most likely outcome is mild gastroenteritis. Advised to continue monitoring at home for any signs of illness.- Discharge home for close monitoring.    Vital Signs    

CLIENT DISCHARGE NOTESPRESENTING CONCERNS: Trouble walking/painfulPROBLEM LIST FROM PHYSICAL EXAMINATION AND HISTORY:Intermitent pain when palpating over left proximal shoulder regionHistory of not wanting to walk and vocalising at homePrevious renal injuryASSESSMENT: Intermitent pain left shoulder of unknown cause. Majof differentials include: Soft tissue injury vs nerve injury vs neoplasia/cancer vs other. PLAN/DISCUSSION: Discussed options of sending Archer home with oral pain relief and to give a one off methadone injection to help settle any pain wind up. Owner has opted to start with just one form of pain relief for now - Gabapentin. Archer may require further diagnostics eg x-ray if the problem persists. TREATMENTS ADMINISTERED:NilMedications for Administration at Home:20.00 x Gabapentin 300mg Capsules Please give One capsule orally every 12 hours, can cause sedation.40.00 x Gabapentin 100mg CapsulesPlease give two capsules every 12 hours - can cause sedation.SPECIFIC HOME CARE INSTRUCTIONS:The Animal Emergency Service advises a reassessment with your regular vet within 48 hours to monitor your pets progress.  If your pet's condition deteriorates or they become flat or lethargic, go off their food and water, develop vomiting or diarrhoea or if you have any concerns please contact the Animal Emergency Service or your regular vet immediately.Thank you for trusting the Animal Emergency Service with the care of Archer.    Vital Signs    

Reason: In PainHISTORY: Was normal for majority of the day, ate dinner normally. When Archer started yelping and appeard to have muscle twitching/spasm left left/shoulder area. Has kyphosis/arthritis over lower back - dx via acupuncture vet. Current meds: NilProphylaxis: NilPre-existing conditions: ArthritisAccess to toxins eg. Rodenticide: None knownTRIAGE:HR: 80RR: 20Temp: 38.5Mm:  PinkCrt: <2Mentation: QAR/AnxiousPain Scale (0-4): 1Hydration status (%): AdequateEXAMINATION:Body Condition Score: 5-6/9Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMusculoskeletal: ambulating normally, Intermitent pain when palpating over left proximal shoulder region (vocalised twice, however not easily repeatable), no notable mass or swelling. Gastrointestinal:- Oral: normal, no mouth pain, dental score (1-4):  1-2- Abdominal: no detectable pain on abdominal palpation, normal gut sounds- Rectal: no detectable abnormalities, faeces:  Urinary: NSFReproductive (incl ext genitalia): NSFIntegument/Ears: NSFLymph Nodes: peripheral lymph nodes normalEyes: NSFPROBLEM LIST:Intermitent pain when palpating over left proximal shoulder regionHistory of not wanting to walk and vocalising at homePrevious renal injuryASSESSMENT: Intermitent pain left shoulder of unknown cause. Majof differentials include: Soft tissue injury vs nerve injury vs neoplasia/cancer vs other. PLAN/DISCUSSION: Discussed options of sending Archer home with oral pain relief and to give a one off methadone injection to help settle any pain wind up. Owner has opted to start with just one form of pain relief for now - Gabapentin. Archer may require further diagnostics eg x-ray if the problem persists. TREATMENTS ADMINISTERED:NilMedications for Administration at Home:20.00 x Gabapentin 300mg Capsules Please give One capsule orally every 12 hours, can cause sedation.40.00 x Gabapentin 100mg CapsulesPlease give two capsules every 12 hours - can cause sedation.------------------------------------------------------------------------    Vital Signs