C09998593 / invoice 10000

Reason: VomitingSubjective:Presenting for:Acute vomitingPossible dizziness, mild lethargy, increased water consumptionPossible ingestion of plant potting material (core portion) from balcony on MondayFrequency of issue: Multiple vomiting episodes over 24 hours - overnight, during morning walk, and at homeLast ate: Still eating well despite vomiting episodesDiet: Regular diet not specified. Normally receives chicken and duck treats (chicken lung, dried chicken and duck treats)Disease prophy:   Microchip: Y/N - scanned - ok?Objective:Clinically stable acute vomiting patient with suspected dietary indiscretionMentation: BAR but mildly lethargicHydration and body condition ok.EENT: NVL clean and discharge freeOral: Mild calculus on a few teethLN: No Sig FindingsChest: Normal heart rate, no murmur detected. Heart auscultation normal Normal respiratory rate. Lung auscultation normalAbdo: No obvious masses palpable, no pain on palpation Mild burping noted. No flatulence. No abnormal gut sounds on auscultation. No hunching or signs of abdominal discomfortMSK: No Sig FindingsSkin: okUrogenital (including mammary glands): No Sig FindingsRectal: T 38.2Neuro: No Sig FindingsOther: Patient is spayed. Weight 6.5kg. Possible slight dizziness noted when harness applied (went off at an angle rather than usual running off)Assessment: Acute gastroenteritis secondary to suspected dietary indiscretion (plant material ingestion) versus viral etiology1. Acute vomiting (multiple episodes over 24hrs)2. Mild dental calculus3. Mild lethargy4. Mild burpingDDxAcute vomiting DDx:- Dietary indiscretion (plant material ingestion - most likely given history)- Viral gastroenteritis- Foreign body obstruction (less likely given no palpable masses, normal gut sounds, still eating)- Metabolic disease (less likely given clinical stability and normal physical exam)Plan:Gave prevomax 0.65ml s/c (Antiemetic injection). Bland diet prescribed for 3-4 days consisting of boiled or steamed chicken breast (no red meat, no fatty cuts) mixed with boiled/steamed vegetables and rice or sweet potato. Discontinue all treats during this period. If patient returns to normal after 3-4 days, gradually transition back to regular diet. If vomiting persists, return for radiographs/ultrasound and bloodwork.Return if vomiting persists or condition worsens. Otherwise recheck in 3-4 days if not improving, or as needed if returns to normalCommunication:Owner consented to treatment plan. Discussed that if vomiting continues despite bland diet and antiemetic, next steps would include radiographs or ultrasound to rule out foreign body, as well as bloodwork to assess metabolic parameters. Owner aware ultrasounds currently difficult to schedule. Owner instructed to discontinue all treats for next few days. Owner understands to monitor closely and return if condition worsens or does not improve.The above clinical notes were created with the assistance of Astro Scribe under the supervision of the consulting Vet.    Vital Signs    Weight: 6.5;       Temperature: 38.2;       

Reason: See Text ReplyAppointment Notes: Hi Dr Madison, thanks so much for touching base. So far so good, introducing her dry food again and her yawns are big and wide. I e tried to look but only when she yawns and nothing stands out as red or irritated. If there is any change over the next week I'll call and organise to get it all sorted while she is asleep. Thank also for making the appointments a great experience.    Vital Signs    

Reason: CommsHi Annette, just checking how our lovely little Lady is going? Has her mouth stayed pain free? For anything urgent, please call the clinic on 08 9271 3671 otherwise a text response is fine. Dr Madison Selleck, Your Pet's Vet.    Vital Signs