C09972148 / invoice 10000

Reason: Vomiting - Still BrightClient Present: katinaNurse:WvVaccination:over due Preventions:Diet:Current meds & doses:Was HPP discussed? Y / NInsurance: Y / N  if yes, Gaponly claim required today? Y / NClient requests +/- concerns:Additional nurse notes:__________________________________________________________________________HISTORY:Owner presented with concerns about their pet's condition as he has had multiple vomiting episodes in 48 hours. Owner has veterinary background but has been out of the field for fifteen years. Checked vital signs at home including temperature, breathing rate, heart rate, and gum colour. Pet remains bright, alert, and responsive with normal appetite and behaviour. Still walking normally and showing typical activity levels.Current meds: noneVaccination: UTDParasite Prevention: UTDPre-existing conditions: noneAccess to toxins eg. Rodenticide: noneEXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 0Hydration status (%): adequately hydratedCardiovascular: 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): 0- Abdominal: no detectable pain on abdominal palpation. No masses palpable.- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: not discussedPROBLEM LIST:Owner concerns regarding pet's condition, describes that he has been quieter at home. DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Dietary indiscretion vs parasites vs gastroenteritis vs pancreatitis vs foreign body ingestionDIAGNOSTICS:Blood tests and faecal examination plannedASSESSMENT:Pet presented for health check due to owner concerns. Physical examination reveals normal vital signs including pink mucous membranes with good capillary refill time indicating adequate perfusion. Pet remains bright, alert, and maintaining normal appetite and activity levels.TREATMENT:Outpatient consultation with diagnostic testing plannedPLAN:Blood tests and faecal examination to be performedResults to be reviewedCLIENT COMMUNICATION:Discussed owner's concerns and findings from examination. Explained that vital signs and clinical examination appear normal. Outlined diagnostic plan including blood work and faecal testing. Maropitant injection to be given to stop vomiting. If vomiting through maropitant then to revisit for radiographs.    Vital Signs    Weight: 33.7;