C09982468 / invoice 10000

HISTORY:Theo, a 3-year-old male Dachshund, presented for vomiting. The owner reported Theo was well yesterday but became inappetent this afternoon, refusing treats and dinner from around 3 PM. He vomited at approximately 6 PM. A second, larger volume, projectile vomit of clear fluid occurred approximately two hours later. Theo ate normally this morning but has been anorexic since. No diarrhoea has been observed.There is a possibility of foreign body ingestion. The owner found a torn-apart puppy pad today but is unsure if Theo was the one who ingested it. There is also potential access to toads and stones in the home environment, though no ingestion was witnessed. There are no other sick animals at home. Theo had a previous episode of diarrhoea in December which resolved with treatment.Current meds: noneUTD with FTW and vacc Pre-existing conditions: History of gastrointestinal upset (diarrhoea in December).Access to toxins eg. Rodenticide: Potential access to toads and stones.EXAMINATION:BARHR 120RR 16PL ssfp MM pink CRT 1.5sT 37.7Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, - Abdominal: mild abdominal tension on palpation, no definitive pain elicited- Rectal: formed faeces , nsf Demeanour/Behaviour: Quiet but alert, demonstrating some nausea (lip licking).PROBLEM LIST:- Vomiting (acute)- Anorexia- Possible foreign body ingestion DIFFERENTIAL DIAGNOSIS/DIAGNOSIS:- Gastroenteritis- Foreign body obstructionDIAGNOSTICS:Radiology: Digital radiography was performed.Not suggestive of FB obstruction at this stage. Stomach small. ASSESSMENT:Theo presented with acute vomiting and anorexia. Examination revealed mild abdominal tension and signs of nausea. The main concern was a possible gastrointestinal foreign body, given the history of a torn pee pad. Abdominal radiographs were performed and were unremarkable, with no clear evidence of a foreign body or obstruction. Gastroenteritis remains a primary differential.Treatment:Maropitant 1mg/kg sc PLAN:Home into owner's care.If not eating tomorrow morning or vomiting after midnight today, represent. CLIENT COMMUNICATION:Two options were discussed: supportive care with an anti-nausea injection and monitoring at home, or proceeding with radiographs for peace of mind. The owner elected to proceed with radiographs. The cost of the X-ray was quoted as $740. The owner was advised to pay upfront and claim from insurance.The owner was advised that despite the normal radiographs, a non-radiopaque foreign body (like plastic or fabric) cannot be ruled out. The owner was instructed to monitor Theo overnight. If he vomits again or remains inappetent by the morning, he should be re-presented for further evaluation, either here or at his regular veterinarian.    Vital Signs    Weight: 10.9;