C09988254 / invoice 10000

Reason: 3 weeks history of vomitingConsult time: 0520 ECC Vet: TXT History:Sunrise is a 3y MN DSH that presented for 3 weeks history of vomiting. OR that initially Sunrise was throwing up consistently for a couple of days 3 weeks ago after every meal and vomiting was noted to be hours after eating. Sunrise does have a history of overeating and eating fast, so O initially did not think much about the vomiting. However, vomiting was consistent after every meal with vomitus containing undigested food.  Sunrise presented to RV where PEx noted NSF. O noted a decrease in urination after vet visit however has since returned to normal. Sunrise re-presented to RV a few days after as vomiting persisted. Blood test, AUS and UA performed noted possible kidney marker elevation. Sunrise had then stopped vomiting after O had increased frequency of feeding with lesser amounts each time. OR Sunrise started vomiting again yesterday evening before dinner and today morning. Vomitus containing undigested food. O noted that Sunrise did have weight loss as well where Sunrise's spine is more palpable. Sunrise has also been more vocal and there had been constant lip licking noted. A period of hyporexia had been noted but his appetite is now normal. Previous medical history: - Existing GI issues especially with diet changes. - History of wheezing episodes couple of years ago with intermittent episodes, last few months ago.Current medication: Gabapentin dispensed by regular vet during last visit, last given: over 48 hours ago orally.Diet: Trilogy and Dine wet food Appetite: Appetite normalVomiting: Consistent vomiting after every meal over last three weeks, vomiting once before dinner yesterday and once this morningDefecation: Nil d+Urination: Decreased urination noted after blood test but has returned to normalAccess to toxin: None knownEnvironment: Indoor only, other cat at home Prophylaxis: Not up to dateObjective:Mentation: HR: 160RR: 24Temp: 38.4MM: pink CRT: 1-2sHydration status (%): clinically euhydratedWeight: 6.5kg Body Condition Score: Muscle condition score: 3/3Cardiovascular: No murmur or arrhythmia noted bilaterally. SSFPRespiratory: Normal clear BVs bilaterally, respiratory effort normalEyes: No blepharospasm, epiphora or episcleral injection noted bilaterallyEars: No lesions or discomfort notedOral: No lesions or mass notedAbdomen: Soft and comfortable, nil fluid wave or nausea notedUrogenital: No lesions or discharge notedLymph Nodes: All LNs WNL for size, non-fixed, non-painful.Integument: No lesions or alopecia notedMusculoskeletal: Weight bearing normally on all four limbsNeurological: Full exam not performed – mentation appropriate, no overt dysfunction noted.Rectal: Not performedLaboratory:PCV/TP 36/70, clearVBG @ 0612pH: 7.339 (7.226 - 7.422)CO2: 45.7 mmHg K+: 3.8 mmol/L (3.3 - 4.6)Na+: 153 mmol/L (151 - 158)Ca2+: 1.28 mmol/L Cl-: 119 mmol/L (117 - 128)Glu: 11.3 mmol/L (4.1 - 7.2)Lac: 0.9 mmol/L (0 - 3.3)BE: -1.2 mmol/L HCO3: 22.2 mmol/LIn house UA USG 1.022Dipstick: BLD 2+ PRO TracePH 7Wet prep: NSFDry prep: NSFLaboratory:None todayAssessment:Problem list:Treatment:Plan:    Vital Signs