C10023936 / invoice 10000

Reason: Ingested Grape VinesHistory:Owners have not been a home for the whole day. Noticed a grape vine on the floor.Owner ate grapes yesterday but have been very careful not to leave any grapes around. Unsure where Biscuit got the grape vine from and whether there were grapes on the vine prior to ingestion.Otherwise healthy - eating, drinking, urinating and defaecating well.No vomiting or diarrhoea, coughing or sneezingNo comobidity except recurrent ear infection which had been managed with topical ear mediationsNot on other medicaitonsExamination findings:BARTemp: did not takeCardio: HR 108, no murmur or arrhythmia. Strong pulse quality (femoral), synchronised bilaterally. CRT <2s, mm pink.Resp: RR 32, normal bronchovesicular sound. No crackling or wheezing. Normal respiratory effortAbdom: soft and comfortable. No overt masses.Uro: NSF, normal external genital, no abnormal dischargeMsk: ambulatory, weight bearing on all four limbs, normal gait. Neuro: normal mentation. LN: bilaterally symmetrical, no enlargementInteg: NSFEyes: NSFEars: NSFOral: NSFEmesisApomorphine 0.03mg/kg SCEffect: productive vomit, large amount of food, one 20cm threadMetocloprimide 0.4mg/kg SCLaboratory:Crea 68Urea 6.1Assessment:Possible ingestion of grape or grape vine during the day - emesis induced, no evident of grapes or vines in vomit, cannot completely rule out remanent of grape/vine in stomach or in intestine. Gold standard treatment was fluid therapy for 2-3 days and repeating renal parameters q24hNo azotaemia currentlyIncidental findings - linear FB in vomitPlan:Charcoal 2g PO once tonight then another 2g 4-8h afterwards.Repeat renal parameters in 24hClient communication:Discussed risk of emesis and remnant of grape material in stomach and intestine. Discussed grape ingestion risk - kidney injury etc. Client elected to take home    Vital Signs    Weight: 7.8;       

Reason: Ingested Grape VinesPresented and seen by Dr     @ Time/DateRegular Vet:Presenting Problem:History:Any current medications:Any access to potential toxins?:E/D/U/D:Any known conditions:Preventatives up to date? Y/NExamination Findings:General demeanour:Temperature:Cardiovascular:Respiratory:Oral exam:Abdomen:Peripheral LNs:Eyes/Ears:Integument:Musculoskeletal:Gait:Neurological:Rectal exam:Urogenital:Body Condition Score:Initial Assessment:Client Communication:Laboratory:Radiographic Findings:Ultrasound Report:Current problems:Differentials:Prognosis:Treatment:Plan: Daily update emailed to referring vet: YES/NOFinancial update provided to owner: YES/ NO    Vital Signs