C10018440 / invoice 10000

DATE/TIME of CONSULTATION: 26/11/21
CLINICIAN: JOhn Le Nepveu
PRESENTING COMPLAINT:Eaten a cupcake

HISTORY:
recent cupcake ingestion
chocolate flavoured cupcake
Asymptomatic

CLINICAL FINDINGS:
BAr
MM pink
CRT 1.5
Fem P's Ok
Hr 120
RR 20
ABDo NAD
Temp 38.5

DIAGNOSTIC TESTS:
EMESIS with apomorphine
1 tab placed in sub-conj space
Vomited until dry retching
The remainder of the tab washed from the eye with saline

Metoclopramide 0.25mg/kg SC
1 cupcake wrapper retrieved

DIAGNOSIS:
Cupcake ingestion

TREATMENT PERFORMED:
Apomorphine 
Metoclopramide

PLAN: 
Home under obs toniggt

CLIENT COMMUNICATION:
Monitor for aggitation, tremors
- review again o/n

PROGNOSIS:
Good

DATE/TIME of CONSULTATION: 14/9/19 2230
CLINICIAN: Claire Lawrence
PRESENTING COMPLAINT: sore back? back legs?
HISTORY: Was normal earlier in the day. Then became quite, but more whiney, seemed off balance on hind limbs and was lifting forefeet up from time to time. Doesn't want to sit or jump. Had sore knees recently and meloxicam gave tummy upset so only had one dose. Otherwise healthy. Diet of RC dachsy - currently transitioning. Also gets antlers, no chicken necks. Ate at 530 pm with no concerns. 
CLINICAL FINDINGS:
Anxious, loves treats
MM pink, CRT<2 HR 128 with owners, good  pulse quality
RR 28, normal BV sounds, no effort
Abdo palp NAD
Temp: 39.1
MSK exam -dips when palpated on right lateral spine just cranial to ischium, otherwise no CP deficits, withdrawal and deep pain intact, still reacts to stifle palpation bilaterally
DIAGNOSTIC TESTS:
nil
DIAGNOSIS:
facet strain? IVDD, other ST injury
TREATMENT OPTIONS PROVIDED:
no indication for CT at this point
TREATMENT PERFORMED:
1. Buprenorphine 0.06mg SC
PLAN: 
Trail carprofen 10mg PO SID start tomorrow AM.
If diarrhoea commences then consider onsior or previcox

CLIENT COMMUNICATION:
possibly Facet strain, IVDD, stifle disease
Rest and NSAID
Return if deteriorates
Follow up with RV MOnday/Tuesday
PROGNOSIS:
good