C09999141 / invoice 10000

REASON: Ate a grapeTime: 2330AES Vet: Romy SaundersRegular clinic: UnknownHISTORY:Suspect grape ingestionEXAMINATION:HR: 120RR: 20 Temp: 38.2MM: pink, moistCRT: 1-2sMentation: BARPain Scale: 0Hydration status (%): euhydrated, euvolaemicWeight: 5.1 kgBody Condition Score: 4.5/9Cardiovascular: 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, dental score: 1/4 - Abdominal: no detectable pain on abdominal palpation, normal gut sounds - Rectal: no detectable abnormalities, faeces:  Reproductive (incl ext genitalia): vulva normal anatomyIntegument/Ears: clean furcoat no evidence of otitisLymph Nodes: peripheral lymph nodes normal size/shape & not painfulEyes: clear corneas, nil discharge or blepharospasmASSESSMENT AND PLAN:1. Grape toxicityVomiting successfully inducedNo grapes produced in vomitus.Anti-emetic medication administeredMay feel flat for next 12 hours following treatmentRest at home recommendedMonitor for recoveryCLIENT COMMUNICATION:Discussed that Rosie likely avoided serious complications from grape ingestionExplained that feeling flat for next 12 hours is normal following induced vomitingAdvised rest at home and offering small amounts of foodEmphasised importance of keeping grapes away from RosieNo medications to go homeDIAGNOSTICS:NoneTREATMENT:Apomorphine 1/2 tablet OTMMetoclopramide 0.5 mg/kg SCPLAN:Rest at homeOffer small amounts of foodMonitor recovery over next 12 hoursPrevent future grape accessIf any decline in next 48 hours, consider revisit and renal panel.    Vital Signs    Weight: 4.9;