C09994137 / invoice 10000

REASON:Time: 06:56AES Vet: Nerida Warburg BVSc(Hon) Regular clinic: North Hobart VetHISTORY:Vomiting and retching with suspected foreign body (Pepsi can) ingestion on 04/03/2026.Assessed at North Hobart Vet on 04/03/2026; examination and X-ray revealed no abnormalities.Eating slowly since the incident, which is reported as normal behaviour.Two episodes of retching with 2x V, initial multiple small pieces of metal - black looks like pepsi can from hx & small furry ball ~1.5cm diameter - leg or something from Teddy or toy & then frothy vomit containing a small amount of blood today, 06/03/2026.Mentation is bright and normal.PMHx: Anxious on fluoxetine & pregaba.Diet: Dry and wet food.Allergies: No known allergies.Normal diet wet & dryEXAMINATION:HR: 120 bpmRR: 28 brpmTemp: 37.8°CMM: Sl tackyCRT: 1-2 secondsMentation: Bright, alert, responsivePain Scale: Nil Hydration status (%): Mildly dehydrated (~5%)Weight: 12.5 Body Condition Score: 4/9 Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal: - Oral: normal, no mouth pain  - Abdominal: soft and non-painful on palpation, no masses palpable, normal to sl reduced gut sounds - Rectal: normal stool NSF Urinary: bladder smallReproductive (incl ext genitalia): desexed, prepuce normal anatomyIntegument/Ears: clean furcoat no evidence of otitisLymph Nodes: peripheral lymph nodes normal size/shape & not painfulEyes: clear corneas, nil discharge or blepharospasmDrinking water in consultASSESSMENT AND PLAN:1. Gastrointestinal Upset / Suspected Foreign BodyAssessment: Suspected gastrointestinal foreign body or gastroenteritis secondary to dietary indiscretion. Mildly dehydrated based on tacky mucous membranes. Normal/comfortable on abdominal palpation.Recommended diagnostic tests: Advised repeat abdominal X-rays and diagnostic abdominal ultrasound to investigate for a foreign body. Blood gas analysis at least recommended +/- IVF. Treatment plan: Pain relief and anti-nausea medication if clinically indicated. Intravenous fluids if dehydration worsens or if hospitalised.Follow-up care: Recommended transfer to regular vet (North Hobart) for further investigation and management.CLIENT COMMUNICATION:Discussed findings with the carer. Explained that while Leo seems comfortable, the history of potential foreign body ingestion and recent vomiting with blood is a concern.Advised that transfer to their regular vet, North Hobart, is the best course of action for continuity of care and further diagnostics like repeat imaging - various typer of imaging & none 100% accuracy.Discussed with Paula, and updated her on the findings and recommendations.DIAGNOSTICS:- NoneTREATMENT:- NonePLAN:Paula happy for transfer & admit to NHVH by carersAdvise transfer to North Hobart Vet for further work-up, including potential repeat X-rays and/or ultrasound.Monitor for any signs of deterioration, including persistent vomiting, lethargy, or abdominal pain.Hx completed    Vital Signs    Temperature: 12.5;