C09979608 / invoice 10000

Reason: R/C V+ And D+Appointment Notes: Special payment terms existHistory:Has only had one vomit in the past month. Client was not home when this happened - her brother saw it. She isn't sure if it was a furball or a true vomit. Previous medical conditions - Suspected IBD, gingivitis 108 and 208Current meds - Gucci stopped eating the Fortiflora so hasn't had this for awhile.Diet - Gucci will not eat the Hills z/d wet food. Client has stopped the ZiwiPeak and is only giving the RC gastrointestinal wet, which is the only wet he will eat. Examination:Has gained 90g since last visit.Temperament/Demeanor: BARChest Auscultation: No murmur/arrhythmias, lung sounds clear. Synchronous femoral pulsesOral: Grade 2/4 dental disease affecting 108 and 208 - mild to moderate gingivitis, mild tartar formation. Other teeth in good condition.Eyes/ears/nose/throat: NADAbdo palp: Soft and comfortable. NAD. Skin/coat: NADGait: nADMSK: Not examined today. LNs: NADNeuro: NADRectal/urogenital: NADAssessment: Improvement in GI signs - due to stopping Ziwi Peak? Histadine in lamb or venison impacting GIT? Vs stopping Fortiflora? Client Communication:Discussed that signs are currently controlled and body condition is acceptable. Advised to continue current diet and monitor. Discussed that probiotics may or may not suit individual cats due to unique gut flora. Discussed dental care at home - start with gauze pad, can progress to Maxigard gel with chlorhexidine applied to gums to help resolve/slow gingivitis. Advised to start with pad only, do daily, and follow with a treat to create positive association. Discussed waiting at least three months before rechecking intestinal ultrasound to allow adequate time for changes to settle.Treatment:NILPlan:Continue current diet and monitor. Start daily dental care with gauze pad, progress to Maxigard gel if tolerated. If weight loss, increased vomiting, or flare-up occurs, will consider starting budesonide. Recheck intestinal ultrasound in approx 3mthsRecheck appointment in 1 month - weight and vomitingClient to contact us if does not improve, worsens or have any concerns. Treatment plan given? N Line billed?    Vital Signs    Weight: 4.15;       MMColour: Pale;       HeartRate: 160;       RespirationRate: 44;       BodyScore: 5;       DentalGrade: 2;       CRT: < 2 sec;