C10009026 / invoice 10000

Appointment Notes: dia, vom, drinking +++. klHistory: 5/7 days this week. pooped inside, 2 days ago, very gelatinous poop and vomiting.Just once, bright yellow. Trying to monitor what  she eats but scavenges alot HISTORY:CURRENT DIET:PREEXISTING CONDITIONS: CURRENT MEDICATION: PE:T-HR/CARDIAC-RR/RESP-MM-CRT-LNN-ABD-BCS-OTOSCOPY/EARS: ORAL HEALTH: EYES: MSK: INTEGUMENT: UROGENITAL: CNS: Not routinely examinedPROBLEM LIST:DX:DDX:RX:PLAN:?????HISTORY: Presenting for investigation of being unwell. Episodes of inappropriate urination and defecation inside over the last week (5/7 days). A single episode of vomiting (yellow bile) and gelatinous faeces occurred two days ago. Owner also reports a single night of increased water intake and intermittent lethargy. Appetite is normal. History of scavenging human food.CURRENT MEDICATIONS: Unspecified pain medication for arthritis. Possible joint supplement.PREEXISTING CONDITIONS: Osteoarthritis. Historical bloods (9 months prior) showed elevated urea and ALKP.CURRENT DIET: Unspecified commercial diet. Scavenges human food including grapes, sultanas, crisps, and ice cream. History of coprophagia (human faeces from a potty).PE:- T-N 38.4°C- HR- RR/lungs:- MM-- LNN-- ABD- Soft, non-painful on palpation. Mild lip licking noted.- BCS- Otoscopy/ears:- Oral health:- Eyes:- Msk system: Known osteoarthritis.- Integument: No pruritus or erythema noted.- Urogenital: Not routinely examined.- CNS: Not routinely examined.Lab:- Previous bloods (9 months ago): Elevated urea. ALKP 1300 U/L. ALT, GGT, T-Bili WNL.- Today: Urinalysis recommended, collection pot sent home with owner. Repeat bloods recommended, declined by owner.PROBLEM LIST:1. Acute gastroenteritis (vomiting, diarrhoea)2. Inappropriate elimination3. Polydipsia (episodic)4. Osteoarthritis5. Historical azotaemia and elevated ALKP6. Dietary indiscretionDx: Acute gastroenteritis secondary to dietary indiscretion.DDx: Renal disease, hepatic disease, pancreatitis, cognitive dysfunction.Assessment: The acute clinical signs are most likely due to dietary indiscretion. The patient is clinically well, afebrile, and comfortable on examination today. The underlying historical lab abnormalities warrant monitoring. Scavenging behaviour presents an ongoing risk for both GI upset and potential toxicosis.Rx:- Human-grade fish oil 1000 mg PO SID with food.PLAN:- Monitor for recurrence of GI signs. If signs recur, commence a bland diet (chicken and rice).- Owner to collect a first-morning urine sample for urinalysis.- Owner educated on the toxicity of grapes, sultanas, and xylitol and advised to prevent access.- Re-book Zydax injection in two months.- Return for re-assessment if clinical signs worsen.?????    Vital Signs    Weight: 6.9;