C09989536 / invoice 10000

past couple of weeks V eod
after having food or a period after
sometimes chunks of food sometimes yellowish
wants to eat and eats well
moved house 10/2
did start a bit before that
weeing and pooing ok
rc sensitivity or applause chicken breast
was throwing with the rc

Type of Appointment: F3 vac with vet 
Time of Appointment: 2.40pm Mon 17/11
O responded N to SMS reminder
Have cancelled the booking 

REASON: Vomiting
Nurse: MH
Presented by: Rafid + Fatima
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HOME CARE AND PREVENTIONS
Vaccinations: UTD
Nutrition: Ziwi Peak + Fancy Feast wet
Worming: Nil
Hwp: Nl
Flea Treatment: Nil
CE: 
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SUBJECTIVE / HISTORY: 
C/O vomiting on and off, suspect may have chewed on something and tried to swallow it. Vomiting episodes have occurred in the past but usually ceases for long periods.
- Vomiting occurred approx. 15 mins after eating. Vomitus initially contained undigested food (biscuits still formed), followed later by clear liquids.
- Noted to be nauseous, especially when eating.
- No vomiting for the past 24 hrs.
- Currently being fed cooked chicken breast, which appears to help settle the stomach.
- PMH: History of previous vomiting episodes.
- Vaccinations: UTD.
- FH: No recent flea/worm/heartworm treatment ("haven't done it in a while").
- Environmental: Totally indoors, which reduces risk of parasites, though some risk from mosquitoes remains.
- Diet: Combination of wet food (Fancy Feast, Weruva) and freeze-dried food (ZP). Currently on cooked chicken breast mixed with rice to settle stomach.
Indoor Only
Vomit started 2 days ago, no vomit for past 1 day but has looked nauseous. Undigested food at the time then liquid >hr later 
Was vomiting after each meal approx 5-10m after, has kept food down for past 24hrs but O noticed a gag after eating
Does chew lots of different things
O had few cooked chicken breast for last 24hrs.
No stool passed since 1 day ago - normal stool
Does scratch at ear, was very red and slightly bloody
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CURRENT / ONGOING MEDICATION AND SUPPLEMENTS:
Nil
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OBJECTIVE / EXAM:
ASA Status (1-5): 2
BCS (1-9): 6
DS (0-4): 0

T: - 38.8
P: >140
R: nad

APPEARANCE/DEMEANOUR: nad, hydration good
SKIN & COAT: Good hydration
EARS: Red area around L ear
EYES: nad
ORAL: nad
MM: pale pink
CVS: reg, nil murmur
RESP: clear on auscultation
ABDO/GIT: Soft, nil pain on palpation, cranial abdomen 'squishy'
UROGEN: Moderate sized bladder
NEURO: nad
MSK: nad
LN: nad
n : Normal     - : Not Examined
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ASSESSMENT: 
Problems:
history of eating things he shouldn't , vomiting poss regurgitation then later vomit for 24hrs a day ago, vomiting now resolved and keeping food down but still appears nauseous

Ddxi:
Foreign body ingestion, gastrointestinal upset

Further Procedure & Diagnostic Needs [Client Response]:
appears to be improving however if starts vomiting or regurgitating again then needs further workup 
next step would be admit for sedation full bloods comp and fpl , iv fluids and imaging abdomen xrays plus minus ultrasound

Medication:
prevomax and sensitivity food small frequent meals


Ongoing medication prescriptions? Renewed prescriptions: 
[a] = Appointment     [d] = Deferred     [w] = Waived     [x] = Do it now
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PLAN / CE: 
rv if any further vomiting or regurgitation
rv tomorrow morning if not improving revisit for admit bloods comp and fpl, iv fluids and abdominal xrays plus minus ultrasound
if better tomorrow then examine ear , do cytology and address itchy ear issue
Finalised by bsc
Rec = Recall     Rev = Revisit     Rem = Reminder