C09979118 / invoice 10000

HISTORY: REASON – In for annual health check and vaccination - NO VACC TODAY

HISTORY - O rescued P from challenger vet - had been eith for about 3 years - O moved recently to new house - last 2 weeks has started vomiting diarrhoea and no appetite - 2 weeks ago mix of hair and food + food - no energy (next day fine) - at night throwing up again, following 3 days after he was fine, then 3 days ago was throwing up water then nothing, then was food+hair and then eating grass - can also be lethargic. OR P only has tummy issues once and then never again when P was about 1 year old
OR O has been feeding same diet - only change is moving house - O has 2 cats at home (other is fine) OR feeding only at night his regular meals
O had P vaccinated - due f3 sept 2026

indoor/ sometimes outdoor 
Appetite:off/on
Water intake: WNL
Urination: WNL
Faeces: off/on
Energy levels: off/on
Coughing or sneezing: no
Vomiting: off/on
Diet: dine wet food (fish) + RC dry food
Parasite Control: advocate topspot - last one december
Last Vaccination: sept 2025
Current Medications: none

EXAMINATION
Demeanour: BAR - lovely boy - will be very unhappy when giving inj but 
BCS: 7/9
Integument: normal
Eyes: clear
Ears: clear
Nose: clean
Mouth:-
CRT:    <2 sec       
MM: pink and moist
Dental disease: Grade - 1/4
HR: 170  BPM,    Rhythm: no murmur or arrhythmia
RR:   BPM,    Effort: normal bronchovesicular sounds
Temp:   NC
Peripheral LN's: normal 
Abdomen: soft and comfortable
Musculoskeletal: weight bearing on all fours
Neurological: NAD
Urogenital: NAD
Rectal: not assessed

ASSESSMENT:


CLIENT COMMUNICATION:
discussed ideally get stool sample (fecal PCR) to get tested for type of bacteria (if present) first - if not any results then may be food allergy, and will have to investigate that further
will give 2 inj today for nausea/vomiting
advised to do topspot monthly

TREATMENT:

PLAN:
O to bring in fecal sample at any time to reception for us to send off PCR to vetpath - booked in consult in 1 weeks time to recheck, can relay results then or earlier if concerned

ESTIMATES: n/a

REVISIT: 1 weeks time

ADDITIONAL DISCUSSED:
1, Dental COHAT: YES/NO
2, Desexing: YES/NO/Not applicable
3, Insurance YES/NO
4. Vaccination Reaction: YES/NO
5. Given relevant handouts and pet report card YES/NO
6. Booked for next vaccination  (            )    in 12 months time  YES/NO
WEIGHT: 6.8