C09995814 / invoice 10000

HISTORY: Presenting Complaint: Blood on her faeces
Regular vet:

History:
Been really well. This morning she passed fresh blood on her faeces. Acting still herself.
Yesterday afternoon at 5PM she nibbled on something she shouldn't. 
Ate dinner last night, doesnt get breakfast. 


Appetite: normal 
Water intake: normal
Urination: normal
Faeces: normal poo with blood around it and next one more developing into HGE
Energy levels: normal
Coughing or sneezing: none
Vomiting: none
Diet: Is on biscuits only. May get an odd chips. Some scraps such as steak
Parasite Control: overdue
Vaccination status: overdue
Current Medications: none

Observation:
EXAMINATION
Demeanour: 
BCS: /9
Integument: 
Eyes:
Ears: 
Nose: 
Mouth:-
CRT:           
MM: 
Dental disease: Grade - /4 104 chip fx of the tip
HR:   BPM,    Rhythm:
RR:   BPM,    Effort:
Temp:   C
Peripheral LN's: 
Abdomen: 
Musculoskeletal: 
Neurological: 
Urogenital:
Rectal:

Assessment:

Client Communication:

Plan:

HISTORY: REASON – 
Seems very uncomfortable 

HISTORY - 
Has been making a regurg sound for the last 2 weeks.
O was concerned hadn't defecated since Sunday but did today. 
Eating grass lately.
Last night was distressed/agitated, couldn't settle, walking around retching. 
Seems better today. 

Appetite: NAD
Water intake: NAD
Urination: NAD
Faeces: Less frequent. 
Energy levels: NAD
Coughing or sneezing: NO
Vomiting: NO
Diet: Kibble
Vaccination status: Overdue - discussed with owner and he will book her in in a couple of days time once we are sure that Febe is well as she had mild fever today.
Current Medications: NIL

EXAMINATION
Demeanour: BAR
BCS: 5/9
Integument: 
Eyes- Clean, no discharge
Ears: Clean, no discharge
Nose: Clear, no discharge
Mouth: CRT <2 secs, MM: Pink and moist
Dental disease: Grade - 0-1/4
HR: -- BPM, normal rhythm. no murmur detected
RR: -- BPM, normal bronchovesicular sounds bilaterally.
Temp:   39.5C
Peripheral LN's: 
Abdomen: soft and comfortable for palpation, no evidence of organomegaly
Musculoskeletal: Weight bearing and ambulatory on all four limbs
Neurological: No neurological abnormality noted
Urogenital:
Rectal: 

ASSESSMENT:
Suspect Febe may have been eating grass and had some lodged in throat.

CLIENT COMMUNICATION:

PLAN: 
Try and limit Febe from eating grass.
O to take temperature at home this afternoon, if it is still elevated or deteriorates at all to bring her back in.
WEIGHT: 9.80

HISTORY: RM post op check
O reports febe has been doing really well. Hard to keep quiet but has been happy within herself. Cone has been off for a week.
EDUF okay. Reduced appetite while receiving NSAIDs, better now.
Sx site looks good. No swelling or redness.
No recheck required.