C10007829 / invoice 10000

GapOnly Summary
In-House team to paste into OpenVPMS
Presenting Complaint
- Acute vomiting with drooling, retching and apparent nausea, onset approximately five hours prior to presentation; not eating today but drinking water.

Prior History
- Yes.
  - Occasional mild vomiting associated with grass ingestion; episode of chocolate ingestion two weeks ago (not considered related); previous history of bladder stone removal (November); no chronic gastrointestinal disease reported.

Assessment
- Open.

Treatment
- Injection of antiemetic administered.
- Dispensed a short course of antiemetic medication for home use.
- Deworming tablet given (catch-up dose).
- Client instructed to monitor for ongoing vomiting, lack of faecal output, or deterioration and advised to seek further diagnostics if symptoms persist or worsen.
- Follow-up phone call scheduled for the next day; revisit recommended in approximately four days.

Completed by Dr Oosthuizen
Consultation Date: 22 February 2026, 08:48 AEDT
HISTORY
Presenting complaint:
- Vomiting and diarrhoea after suspected ingestion/allergic reaction to grass or wisteria, possible rashes and facial swelling reported by owner
- Recent episode following ingestion of chocolate (Old Gold with peanut brittle)
Previous vaccination:
- N/A
Parasite control:
- N/A
Diet:
- Hills Urinary Care c/d (kibble and tins)
- Occasional chicken products (frozen given in past)
- Owner notes Cleo tends to quickly eat food without chewing, prefers bigger chunks to encourage chewing
Weight change since last visit:
- Current weight: 12.9 kg
Current medications & medical conditions:
- Metaclopramide administered during visit
Client concerns:
- Suspected allergies to grass, wisteria, and possible spider bites
- Facial swelling and rashes occurring unpredictably
- Vomiting after eating chocolate product with peanut brittle
- Owner prefers not to undergo extensive diagnostic testing; requests Cytopoint for allergy management
- Concern Cleo may develop urinary stones if diet is not managed

PHYSICAL EXAM
Mentation: BAR
Eyes: NAD
Ears: NAD
Nose: NAD
Oral: Pink mucous membranes, CRT <2 seconds
Dental Grade: Grade 3, back teeth previously treated and rebuilt two months ago, issues noted with Cleo not biting or chewing food, prior food waste observed
Lymph nodes: NAD
Cardiac: NAD
Respiratory: NAD
Abdominal: NAD
Genitourinary: NAD
Musculoskeletal: NAD
Neurological: NAD
Skin & Coat: 5/5
Anal Sacs: NOT DONE
Temperature: NOT TAKEN (noted due to anxiety)
Notes:
- Cleo observed to be recovering post-visit, sulky but rejuvenated after intervention
- Owner reports previous rashes and swelling difficult to observe due to long hair

DIAGNOSTICS
- Clinical Examination

ASSESSMENT
- History of contact allergies (grass, wisteria) resulting in vomiting, diarrhoea, rashes, and facial swelling
- Recent ingestion of chocolate with peanut brittle
- Vomiting episode managed in-clinic
- Dental issues related to Cleo’s eating behaviour, possible risk of future urinary stones

TREATMENT
- Induced vomiting with apomorphine (1 mL IM)
- Vomiting reversed with metaclopramide (1.3 mL IM)
- Cleo monitored post-treatment, improvement observed
- Owner advised to wait a few hours before offering small amount of kibble
- Normal dinner to be resumed if no further vomiting occurs
- Medical summary and itemised invoice to be sent for insurance claim

COMMS
- Owner declined additional diagnostic testing for allergy episode in favour of Cytopoint therapy

ADDITIONAL INSIGHTS
None

RECOVERY CALL
- Recovery call scheduled for 22 February 2026 at 14:40 AEDT to assess:
  - Any recurrence of vomiting or diarrhoea
  - Cleo’s general behaviour and recovery post-treatment

Based on a 25 kg Dog
Only variation is consult type