C09972779 / invoice 10000

reason:InappetenceHistory:Presenting for: Molly presented for post-operative vaccination appointment following recent desexing surgery, with owner reporting 2 days of complete inappetence and vomiting.Historical Conditions:- Recent desexing surgery - surgical site healing well- History of severe pruritus noted at time of desexingDiet:- Complete inappetence for 2 days- Normal diet consists of raw meat in morning, cooked meat and vegetables from owner's plate at night- Owner has offered roasted chicken from Coles (usually favourite), raw meat, cooked meat, cooked vegetables - all refused- Occasionally consuming small amounts of dry biscuitsDrinking/Urination:- Reduced water consumption noted by ownerV/D/C/S:- Vomiting yesterday (twice daily), none today yet- Vomit described as greeny-yellow colour- No diarrhoea- Small but normal faeces productionCurrent Meds:- Meloxicam recently discontinued- Due for monthly deworming tablet (unable to administer due to inappetence)Lifestyle Risk Factors:- Does not typically ingest foreign objects or toys- Scratches frequently on carpetExamination:Mentation: Flat, lethargicT: 39.01°C (slightly elevated)MM: Not as pink as expected, suggestive of mild dehydrationHydration: Mildly dehydrated based on mucous membrane appearanceBehavioural: Quiet, seeking comfort from owner, reluctant to be handledOral: Examination attempted but patient uncooperativeAbdominal: Non-painful on palpation, no obvious masses or distensionIntegumentary: Surgical site healing excellently with no evidence of complications, no protective collar required as patient removes itAssessment:Post-operative nausea and inappetence - DDx: anaesthetic-related delayed recovery, gastroenteritis, metabolic diseaseMild dehydration secondary to reduced intakePost-operative surgical site - healing appropriatelyPlan:Vaccinations:- Vaccination postponed due to patient feeling unwellDiagnostics:- Comprehensive blood panel approved by client (estimated cost ~$500, to be submitted through pet insurance)- Results pending to guide further treatment decisionsAdditional Discussion:- Client will leave patient at clinic for blood collection and initial assessment- Depending on blood results, may initiate IV fluid therapy and anti-nausea medication- Treatment plan to be determined based on diagnostic findings- Estimate provided for up to $1000 treatment with insurance claim to followClient Comms:- Client to attend own medical appointment and return later for results discussion- Will contact client once blood results available to discuss treatment plan- May recommend hospitalisation with IV fluids depending on findings    Vital Signs    Weight: 4.15;