C09996127 / invoice 10000

Reason: Recheck More V+ / Off FoodAppointment Notes: Overdue remindersReason: Client Present:Nurse:Healthy Pets Wellness Testing: Done Yes / NoVaccination Type:Intestinal worming:Heartworm Prevention:Flea Prevention:Tick control:Microchip:Insurance and Healthy Pets Plus:Behaviour concerns:Current medications:Current Diet:Type of Shampoo/Frequency:Toileting:__________________________________________________________________________History: Presented for recheck - seen yesterday for vomiting.. Owner reports two episodes of vomiting last night. A pool of watery vomit was also found on a chair.She was eating gastrointestinal food yesterday afternoon but then was not interested last night. She was also not interested in dry biscuits today.She ate a small amount of cooked chicken breast approximately 20 minutes prior to the consultation and kept it down. Owner thought she abdomen sounded 'gurgling'.She been urinating normally overnight. No faeces have been observed.Lucy was seen chewing on cat grass this morningUTD with vaccinations and preventativesPre-existing conditions:PDA, corrected via surgery at young age. Desexed as matured aged dog >12 months of age, was placed on IV fluids intraopEXAMINATION:QARHR 126 RR 20 MM pink CRT <2sec temp 38.0 earCV no murmurs or arrhythmiasResp normal bronchovesicular soundsAbdomen soft on palpation rectal exam - soft, formed faeces presentSkin soft coatOpth clear eyes, normal pupilsLN submandibular LN NADLaboratory:TAHP bloods WNL (sent to IDEXX yesterday)Normal amylase, lipasePROBLEM LIST:VomitingInappetenceLethargyDIFFERENTIAL DIAGNOSIS/DIAGNOSIS:Suspected viral gastroenteritis.**ASSESSMENT:**Vomiting, inappetance - DDx GI (gastroenteritis, dietary indiscretion, IBD), extra GI less likely since TAHP bloods normal Discussed with owner that the anti-nausea injection from yesterday has likely worn off. There is a concern for mild dehydration due to vomiting and reduced water intake. Discussed administering anti-nausea medication again with SC fluids to help hydrate Lucy, then can monitor at home and see if she keep eating cooked chicken and without vomiting. Owner agreed. **TREATMENT:**-Cerenia 7.8gm SC-Subcutaneous fluids LRS 80ml SC (10ml/kg)-Advised owner to continue offering small, frequent meals of cooked chicken today and tomorrow.-Discussed using an unflavoured electrolyte solution hydralyte can be mixed with drinking water to encourage fluid intake and maintain hydration.PLAN:Home into owner's care.Monitor for further vomiting, changes in appetite, or lethargy over the weekend.If clinical signs worsen or do not resolve, bring back for recheck or take to AEC.CLIENT COMMUNICATION:Discussed the blood results with the owner, no signs of pancreatitis or other severe underlying disease. Vomiting could be due to gastroenteritis. Advised on the treatment plan, including the anti-nausea injection, subcutaneous fluids for rehydration, and dietary management with small meals of chicken. Instructed the owner on signs that would warrant a recheck or to be taken to AEC.Scripts Needed - Yes or NoRevisit needed - Yes or No - ____ Days pleaseHistory-Update:Consent has been given by the client to proceed with this treatment  -  Yes/No Reason: Nurse: -vaccination -heartworm -worming -flea/ticks Exam: Lab: Assessment: Treatment: Plan: IV & Fluid Therapy: Catheter Removal    Vital Signs    Weight: 7.8;       Temperature: 38;