C09985430 / invoice 10000

04/03/2026 DATE/TIME of CONSULTATION: 14:43hrs, Wed 04/03/26
CLINICIAN: Josie Sinclair
PRESENTING COMPLAINT: abdominal pain, retching
HISTORY:
- Managed by medicine for suspected triaditis 
- Recently started Prednisolone and Clavulox

- Woke this morning with odd abdominal spasming, and occasional dry retching (more of a cough than a retch)
- O gave ondansetron which didn't resolve it
- No diarrhoea, no productive vomiting
- Not much interest in food or water

- Since scope last week, hasn't been eating as much (even with mirtazepine)
- Current meds: Clavulox + Prednisolone + Mirtazepine + Ondansetron 

CLINICAL FINDINGS:
EENO: MM pink and moist, CRT <2s
Cardio: HR 180, no murmur or arrhythmia
Resp: RR 28, no abnormalities on ausc
Abdo: tense and uncomfortable, intestines thickened and ropey
MSK: no lameness or discomfort on palpation
Neuro: QAR, no obvious deficits

PROBLEM LIST:
1. Retching
2. Abdominal pain
3. Suspect triaditis 

ASSESSMENT:
Acute onset retching and abdominal pain - likely secondary to underlying triaditis or other GI pathology. Supportive care indicated while awaiting medicine work up.

TREATMENT:
Administered:
- Maropitant 1mg/kg SC
Dispensed:
- Buprenorphine 0.3mg/ml - 0.2ml PO BID
Continue current medication - use Ondansetron persistently for at least 2 days
Ongoing plan pending Medicine work up