C10021793 / invoice 10000

Appointment Notes: VETSTORIA - Cookie (Dog) - Consultation - Unwell Pet [Veterinarian : Dr Andrew Eaton(No Preference)] - Vomiting. She ate sand at the beach - Web BookingClient name: Johanna SingerContact number: 0422200420Email address: joanna0908@hotmail.comPatient name: Cookie Original Appointment Type: Consultation - Unwell Pet?????Subjective:History: The owner reports that Cookie became unwell this morning with vomiting. She was at the beach yesterday for approximately 15 minutes and was observed eating sand. The owner is concerned about sand ingestion.- Clinical signs/progression: Presented for acute onset vomiting. Had three small "sandy biscuit" like vomits this morning; no further vomiting since. Was lethargic and shaking this morning but has improved, showing more energy prior to consultation. Passing sand in faeces, but faecal volume is reduced.- Significant history: Previous episodes of gastrointestinal upset described as "sore tummies".- Current medications: Owner mentioned non-specific "tablets".- Appetite & diet: Ate a small amount of food and drank water before the appointment.Objective:Vital Signs:- Blood Pressure: Not mentioned.- Heart Rate: Normal rate and rhythm.- Respiratory Rate: Not mentioned.- Temperature: 38.7°C.Demeanour: Bright and alert. Improved compared to this morning per owner's report.Examination Findings:- Eyes: Not mentioned.- Ears: Not mentioned.- Oral: Not mentioned.- Nose: Not mentioned.- Peripheral lymph nodes: Not mentioned.- Cardiovascular: No abnormalities detected on auscultation.- Respiratory, breathing: Not mentioned.- Urinary/Genital: Not mentioned.- Skin: Not mentioned.- Abdomen: Tender on palpation.- Rectal examination: Not mentioned.- Neurological: Not mentioned.- Musculoskeletal: Not mentioned.- BCS: Not mentioned.- Hydration: Not mentioned.- Other Findings: Not mentioned.Problem List:1. Vomiting (acute)2. Abdominal pain3. Suspected sand ingestion/impaction4. Reduced faecal volumeAssessment:Acute gastroenteritis with abdominal pain, secondary to suspected sand ingestion. The patient's clinical signs have improved since this morning. The main differential is sand impaction or foreign body obstruction.Plan:Treatment Plan:- Single view abdominal radiograph to assess sand volume and rule out obstruction.Progress Notes:- Clinically improving; vomiting has ceased and demeanour has brightened.Client Communications:- Discussed the risks of sand impaction and intestinal blockage.- Recommended abdominal radiograph for diagnosis and to guide treatment.- Provided a cost estimate of $417 for the procedure.- Owner gave verbal consent for the radiograph.- Advised that passing sand is a positive sign but does not rule out a partial obstruction.- Arranged for patient to be collected between 4:30 pm and 5:00 pm.Allergies:- None known.Additional:- Prognosis: Guarded pending diagnostic imaging results.- Treatment declinations: None. Owner consented to all recommendations.?????HISTORYCLINICAL EXAMINATIONBar VinDDX/PROBLEM LISTTRT    Vital Signs