C09977848 / invoice 10000

Vomiting/Diarrhoea

Reason for presentation:

GAP ONLY CHECK LIST

*Reason for visit: Diarrhoea 2 days duration

*Primary diagnosis/suspected diagnosis/location: dietary, infectious (less likely), other

*Any other conditions being treated (if any): none

*Known health concerns: none

*Date of first clinical signs (if known):  ~2 days ago




SUBJECTIVE/HISTORY:
  Behaviour: FAS (relaxed/mild/moderate/severe) 
      Strategy (protective/avoidant/inhibited/appeasing) 
      Exited carrier () Treats offered () Treats taken () 
      Handling techniques/preferences () 
  Appetite: (normal) 
  Water Intake: (normal) 
  Urination: (normal)
  Vomiting history: (no vomiting)
  Coughing: (no coughing)
  Sneezing: (no sneezing)
  Faeces: (normal) Faecal score ()
  Current diet: ()
  Current Medications: (none) (Pre-visit medications: none)             
  Vaccination Status:  (UTD)
  Most recent endo/ectoparasite treatment: ()
  Housing: (indoors only +/- outdoor enclosure or unsupervised access outdoors)
  Other animals in household: (none)

OBJECTIVE/ EXAMINATION:
Temperature: Normal
Mentation (BAR) BCS: /9   MCS: (1/normal)
Hydration: (No evidence of dehydration)
Mucous membranes pink and moist, CRT <2 sec
Dental/oral cavity: ()
Nose/throat: (No significant findings)
Thyroid palpation: (normal, no goitre palpated) 
Eyes: No blepharospasm, no ocular discharges, fundic exam (), full ophthalmologic exam not performed
Ears: No significant findings, clean. Otoscopic examination not performed. 
HR: () bpm, normal rhythm, no murmur detected, normal synchronous pulses
RR: () bpm, regular, no significant findings on chest auscultation, normal effort
Abdominal palpation: No significant findings and comfortable on palpation
Urogenital: No significant findings, small bladder on palpation 
Integ: skin and coat healthy, no obvious lesions or lumps noted, normal skin recoil
Msk: no obvious limping noted
Peripheral LNs: No significant findings
Neurological: no abnormalities detected, a full neurological exam not performed
Feline grimace score if applicable (nil pain detected)

LABORATORY:
CBC: ()
PCV/TP: ()
BIOCHEM: ()
BLOOD GAS ANALYSIS: (No significant abnormalities)
USG: ()

ASSESSMENT/CURRENT PROBLEM LIST/DDx:
()

PROGNOSIS
(Excellent)

TREATMENT:
()

PLAN:
()

MEDICATION PLAN: 
Commenced:
Continue:
Discontinue: 
Repeat scripts allowed for: (drug name) for a period of ()