C09974244 / invoice 10000

REASON: Drooling, lethargic, not himself
Nurse: CC
Presented by: Dayna
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HOME CARE AND PREVENTIONS
Vaccinations: UTD

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SUBJECTIVE / HISTORY: 
Owner came home from work to find Lenny very lethargic with drool. 
Been outdoor today. Outside when O's not home. 
Vomited twice in consulting room-froth + dog food small amounts
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CURRENT / ONGOING MEDICATION AND SUPPLEMENTS:
-
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OBJECTIVE / EXAM:
ASA Status (1-5): 1
BCS (1-9): 5
DS (0-4): 0

T: 38.7
P: 80
R: n

APPEARANCE/DEMEANOUR: QAR. Groaning in consult(he is verbal at home but not usually verbal in consult)
SKIN & COAT: Normal skin tent. 
EARS: n
EYES: n
ORAL: n
MM: Slightly congested. CRT < 2 sec
CVS: n
RESP: n
ABDO/GIT: realxed on palpation
UROGEN: n
NEURO: n
MSK: n
LN: n
n : Normal     - : Not Examined
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ASSESSMENT: 
Problems:
Acute onset vomiting

Ddxi:
Dietary indiscretioon,snake bite,other

Further Procedure & Diagnostic Needs [Client Response]:
Limited options as presented at 5.50pm

Medication:
Maropitant SC
RC gastrointestinal tins to feed after 1 hour

Ongoing medication prescriptions? Renewed prescriptions: -
[a] = Appointment     [d] = Deferred     [w] = Waived     [x] = Do it now
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PLAN / CE: 
If still vomiting after 7.30pm or any other concerns to contact EVA for appointment
If doing well /stable nurse follow up tomorrow morning to see if need RV
Finalised by REC
Rec = Recall     Rev = Revisit     Rem = Reminder

REASON: Post dental check
Nurse: SP
Presented by: Dayna
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SUBJECTIVE / HISTORY: 
Chewing on sticks and takes fruit off the orange trees
EDUD normally
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CURRENT / ONGOING MEDICATION AND SUPPLEMENTS:
Amoxyclav 500mg 1 tablet BID
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OBJECTIVE / EXAM:
ORAL:Both right and left sides of mouth have healing areas of ulceration
Crusting on RHS has resolved

n : Normal     - : Not Examined
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ASSESSMENT: 
Problems:
healing ulcers

Ddxi:
Likely soft tissue trauma from chewing sticks

Further Procedure & Diagnostic Needs [Client Response]:
Owner to monitor

Medication:
-

Ongoing medication prescriptions? Renewed prescriptions: -
[a] = Appointment     [d] = Deferred     [w] = Waived     [x] = Do it now
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PLAN / CE: 
Rem Semi-AHC with nurse January 2026
Finalised by REC
Rec = Recall     Rev = Revisit     Rem = Reminder

REASON: Post dental & check lip ulceration
Nurse: SP
Presented by: Jake
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SUBJECTIVE / HISTORY: 
One side of lip healing well but other side there isn't much change
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CURRENT / ONGOING MEDICATION AND SUPPLEMENTS:
amoxyclav 500mg 
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OBJECTIVE / EXAM:
ORAL: RHS of mouth small dot of ulceration remaining
LHs side of mouth small dot of ulceration still present

n : Normal     - : Not Examined
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ASSESSMENT: 
Problems:
lip lesions

Ddxi:
bacterial infection vs injury 

Further Procedure & Diagnostic Needs [Client Response]:
- 

Medication:
Amoxyclav 500mg tablets 1 tablet BID (x)

Ongoing medication prescriptions? Renewed prescriptions: - 
[a] = Appointment     [d] = Deferred     [w] = Waived     [x] = Do it now
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PLAN / CE: 
Rev 4 days recheck mouth. may repeat impression smear if no improvements. 
Finalised by jf. 
Rec = Recall     Rev = Revisit     Rem = Reminder