C09988464 / invoice 10000

Reason: Vomiting, Appears PainfulRecord Entered by: MEL History:Presented at 0600h for discomfort overnight. Monti had his dinner in the evening. He then yelped suddenly and then proceeded to vomit twice at about 10pm. Since then he has been up and about. Owner notes that he has been panting. The last yelp was 30 minutes ago. Diet consists of commercial wet and dry dog food. Treats include pizzle treats, sometimes goat horn but he has not had this recently.  Owner notes that he is more comfortable now that he is in the clinicPhysical Examination: Demeanour: BARBCS: 5/9EENT: unremarkableOral: clean adult teethPeripheral lymph nodes: small, symmetrical, not enlargedIntegument: clean coat, no parasites/debris. Fur around the lips is dampCardiovascular: Pulse 112, strong pulse, MM pink, CRT<2sRespiratory: panting, eupneicAbdominal: no discomfort on firm abdominal palpation, no appreciable massesMusculoskeletal: unremarkable. No discomfort on manipulation of any limbNeurological: normal mentation and gaitRectal: Temp 38.5. Slightly loose stool on thermometer sleeve. On rectal, there was also loose, mahogany red/brown faeces with a string of grass and a hard, sharp edged rock/bone like material about 5x5mmUrogenital: externally unremarkable Assessment:Problem list:- vomited twiceDdx: Primary GIT (Dietary indiscretion, Food Allergy, Sudden change in diet, FB, Neoplasia, Intussception, Infection, Parasites, Inflammation, Toxins, Constipation, HGE) vsExtra GIT - (Metabolic disease, Pancreatitis, Drug or Toxin, Inflammation, Endocrine disease, Neuro, neoplasia)- acute, sharp yelping pain- soft stool containing grass and hard material   On physical exam, the pain could not be localized. Primary suspicion is dietary indiscretion causing gastrointestinal irritation but cannot rule out other causes. Explained to the owner that the primary suspicion is gastritis but cannot rule out other causes. As Monti appears clinically well at present, recommended: continued at-home monitoring with the view to re-present if the vomiting reoccurs, the pain persists, and the owner wishes to investigate; trial pain relief to rule out a transient pain noting that selection of the pain relief is limited by the reduced ability to localize the pain; or, admission for investigation including possible imaging.The owner elected to continue monitoring at home.   Plan (incl. alternative options): Owner to monitor for ongoing pain/discomfort and vomiting. Owner to re-present for investigation. Record Entered by: Record Checked by: History:  Physical Examination: Demeanour: BCS:EENT: Peripheral lymph nodes: Integument: Cardiovascular:Respiratory:Abdominal: Musculoskeletal: Neurological: Rectal: Urogenital:  Assessment:  Plan (incl. alternative options): Client Communication:    Vital Signs