C10009905 / invoice 10000

HISTORY:Presenting complaint: Vomiting and inappetence.Vomited once last week, consisting of bile.Vomited bile with a slight pink tinge today.Not interested in eating chicken today, which is unusual.Drinking normally.No diarrhoea.Reported as being a very quiet dog, so difficult to assess lethargy.Current meds: noneVaccination: Not mentionedParasite Prevention: Not mentionedPre-existing conditions: noneEXAMINATION:HR: 130 BPMRR: 20 per minuteMm: pinkCrt: <2 secondsMentation: BARBody Condition Score: 6/9Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronous grade 3/6 heart murmur presentRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeEyes: No discharge, no redness, no blepharospasmEars: No discharge, no inflammationNeurological: neurologically no significant findingsMusculoskeletal: Poor conformation in all four limbs.Oral: grade 3 dental disease. Significant gingival hyperplasia present. Abdominal: no detectable pain on abdominal palpationIntegument: No parasites or inflammation notedUrinary: No significant findingsReproductive: No significant findingsLymph Nodes: No significant findingsPROBLEM LIST:Vomiting with haematemesisHyporexiaGrade 3 dental disease with gingival hyperplasiaDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:GastroenteritisDietary indiscretionDIAGNOSTICS:NoneASSESSMENT:Presented for vomiting and inappetence.Examination was largely unremarkable apart from significant dental disease.Blood tests were recommended to investigate the cause of the clinical signs but were declined by the owner.TREATMENT:Prevomax 2ml given subcutaneously.PLAN:Trial of medical management with Prevomax.If clinical signs resolve by tomorrow, no further action is required.If there is no improvement, further investigations will be necessary.Home into owner's care.CLIENT COMMUNICATION:The owner was advised that no obvious abnormalities were found on physical examination today. The recommendation for blood tests was discussed but the owner declined. A trial of medical treatment with an anti-nausea injection has been initiated. The owner was instructed to monitor for improvement. If Nyla is not back to normal by tomorrow, further investigations will be required.    Vital Signs    Weight: 19.8;