C09976127 / invoice 10000

DATE/TIME of CONSULTATION: 09:07hrs, Sun 01/03/26
CLINICIAN: John Le Nepveu
PRESENTING COMPLAINT:Lethargic

HISTORY:
Nurse notes: lethargic, inappetant
- came home exhausted after a wlak on the beach yesterday, breathing rapidly
- refused food last night/this Am....but ate some chicken this AM
- no gastro signs reported
=- no knonwn underlying med compliants, Beransa once a month for OA

CLINICAL FINDINGS: 
Mentation:BAr HR: 120 RR:24 MM: pinkj and slippery CRT:1.5  Temp 38.4
Borborygmus
Abdo a little sore
Rectal exam- suspected diarrhoea

PROBLEM LIST:
Suspected diarrhoea/AHDS symptoms

OPTIONS PROVIDED:
Home care w medications and syringe feeding

DIAGNOSIS:
Suspeted diarrhoea

TREATMENT:
Ondasnseton wafer PO
Pregabalin capsule PO
Maropitnat inj sc

CLIENT COMMUNICATION/PLAN:
Home to client for BID oral meds and syringe feeding Q 4hrly w a/D provided
Review again if getting worse, lethargic, worseing diarrhoea

DATE/TIME of CONSULTATION: 22:15hrs, Mon 14/08/23
CLINICIAN: amz
PRESENTING COMPLAINT:
seems uncomfortable, 
HISTORY:
ate dinner last night, didnt want breakfast this am
no vomiting or diarrhoea however seems to be trying to vomit
quiet and uncomfortable

CLINICAL FINDINGS:
mm pink crt 2 sec T 38.8 hr 172 RR 52
mild borborygmi
abdominal discomfort
no MSK pain

PROBLEM LIST:
inappetance
abdominal discomfort

DIFFERENTIALS:
dietary indiscretion
dietary intolerance
gastroenteritis
gastric FB

DIAGNOSIS:
GI discomfort

TREATMENT:
maropitant sq and meloxicam sq at 22:30

CLIENT COMMUNICATION/PLAN:
if not happy and eating in am then rv at reg vet 

discussed monitoring for ongoing gi issues and if so then a food trial

DATE/TIME of CONSULTATION: 0430 24/11/19
CLINICIAN: Claire Lawrence
PRESENTING COMPLAINT: vomiting, off food
HISTORY: Ok Saturday but dint eat dinner and then vomited 3 times overnight. May have been some blood in it. or maybe brown Otherwise well. no other health concerns. O due for worming. No access to rodenticides.
PHYSICAL EXAMINATION
Demeanour: QAR, anxious
Cardiovascular: HR 156. No murmur/arrhythmia on thoracic auscultation. Adequate and synchronous femoral pulses. MMs pink and moist. CRT <2
Respiratory: RR 28. Normal effort and bronchovesicular sounds x4 quadrants, nares clear
Abdomen: Mild abdominal discomfort, or mass effect on palpation
Oral cavity: NAD. Dental score 0/4, lip smacking
Eyes / Ears: pupils equal and concentric, ears NAD
MSK: appendicular limbs and spine NSF
Gait: Ambulatory with no gait deficits
Neuro:  Cr nn WNL
Integument: NAD
Peripheral LNs: NAD
Rectal: scant faeces
Temp: 38.8
BCS: 5/9
LOP: 1/4
BW:7.7
DIAGNOSTIC TESTS:
nil
ASSESSMENT:
Acute gastritis  (possible haemtemesis)
TREATMENT OPTIONS PROVIDED:
1. anti-nausea and Gi protectants
TREATMENT PERFORMED:
1. maropitant 7.7mg SC
2. Sucralfate 500mg BID
PLAN: 
blands
return this am if signs persist
CLIENT COMMUNICATION: Investigation (bloodwork, urinalysis, survey radiographs) warranted if failure to improve this morning. 
PROGNOSIS: guarded