C10006373 / invoice 10000

HISTORY: PRESENTING COMPLAINT(S): vomiting

HISTORY:
- owner reports intermittent vomiting since round Australia trip started (12/25)- initially thought carsick but has continued since returning home.
- initially stools soft but now returned to normal
- maybe a bit quiet but otherwise normal and keen to eat.
- not losing weight
EDUF normal? YYYY
Any v#/d#/coughing? vomting- y 6 week intermittent vomiting- generally straight after eating. Food +/- bile coloured fluid.
Current medications: nil
Repeats n/a
Other:
- diet: biscuits in am- RC CKCS biscuits; home-cooked pm - cooked chicken +/- rice and veg, human grade mince (cooked or raw) and veg. No bones.

CLINICAL EXAMINATION:
Temp:       38.58     HR:      128              RR: < 30
Demeanour: BAR
BCS:  3  /5   Weight assessment:           ideal     
Mm colour:   pink             CRT:1    secs
Dental grade: 0  /4
Pain score: 0/5
Sterilised? Y
Significant findings:
1. squelchy GIT on palpation ie increased GIT gas. No apparent pain or palpable mass.

ASSESSMENT: 
Problem List/ Ddx:
vomiting- chronic > further investigation warranted to localise and diagnose aetiol for specific treatment rather than offering only conservative symptomatic management. Start with blood testing and progress to imaging (likely ultrasound) 

TREATMENT:
- nil pending further information

PLAN:
Revisit: for ultrasound 48 h
WEIGHT: 6.40

HISTORY: LABORATORY TEST: CBC, BC, T4, UA

SIGNIFICANT FINDINGS:
1. CBC
- lymphocytosis- marginal (4.86 x 10-9/l normal 1-4.8), 
- thrombocytopenia - moderate 64 x 10-9/l normal 165-500) with macrothrombocytes 11.3 fl normal 3.9-11.1;
> smear- anisocytosis 1+, polychromasia 1+; no platelet clumping and confirmed variable size with some equivalent to RBCs. 

2. BC
- decreased Alk phos (14u/l normal 20-50), 
- hypoglobulinaemia- mild (21 g/l normal 23-52)

3. T4
- normal

4. UA
- USG 1.050
- dipstick: pH 6, protein 1+ on voided sample

ASSESSMENT
- no localising signs
> progress to abdominal imaging (xray if originally eating "wirey stuff" assuming metallic, othewise ultrasound).

PLAN/ TREATMENT:
- O thinks lots of other non-metallic feasible so opts for ultrasound (will need fasting, haircut); booked for Wednesday 2 pm with drop off 1 pm.

Owner contacted: yes
Revisit/ reminder booked: yes

HISTORY: PRESENTING COMPLAINT(S):

HISTORY:
EDUF normal? yyyy
Any v#/d#/coughing? nnn
Current medications: nil
Repeats OK? Yes/ No (If yes - # months/ criteria?) n
Other:

OR crossing the nullabor on thursday to victoria
After xmas might head up to NSW and then come back or maybe just come back
Will be gone for a few months possibly


CLINICAL EXAMINATION:
Temp:  38.2          HR:     116                RR: 32
Demeanour: BAR sweet but timid
BCS:   3/5   Weight assessment:   Good              
Mm colour:    Pink, moist            CRT:   1 secs
Dental grade:   0/4
Pain score: 0/5
Sterilised? Y
Significant findings: Nil

Lovely girl
No concerns
Wormed with pyraquantel in consult
Bravecto spot on applied
WEIGHT: 6.70