C10025571 / invoice 10000

13/03/2026 History:
- Presenting for diarrhoea and coughing/gagging episodes
- Diarrhoea started two nights ago - initially liquid, then formed, then mushy, then watery drops; no blood observed
- Coughing/gagging episodes occurring, particularly after eating
- Vomited approximately two weeks ago when diet changed - initially yellow bile, then off-white/yellow
- Crying after meal last night, not himself
- Off food this morning, not interested in treats
- Clingy behaviour for last 4-5 days
- Recent home renovations with tradespeople present; metal filings on ground - owner has been cleaning up
- Diet: chicken rice congee with chicken kibble, approximately 350-380g per meal (last batch approximately 300g)
- Weight stable: 10.6kg today, previously 10.8kg, 10.6kg, 10.2kg
- Currently on vitamin B1 supplementation

Vital Signs:
- Temp: Normal (within 37-39°C range)

Physical Exam Findings:
- Mentation: Alert
- Behaviour: Cooperative during examination
- Eyes: Normal
- Oral Cavity: Normal; dental cleaning required when feeling better
- Lymph Nodes: Not swollen
- Cardiovascular: Normal
- Respiratory: Lung sounds clear bilaterally, no signs of chest infection; sensitive to palpation at lower mid-throat region with cough response elicited
- Integument: Small pigmentation change noted on nipple

Assessment:
- Problem list:
1. Upper airway/tracheal inflammation
2. Diarrhoea
3. Inappetence

Plan:
- Anti-inflammatory medication: 1ml PO BID for 5 days (can give up to TID if needed)
- Store in dark bag (light sensitive), no refrigeration required
- Improvement expected within 48 hours
- Return if lethargy, not eating, or behaviour changes
- If no improvement, consider throat x-ray imaging
- Dental cleaning to be booked when recovered

Communications:
- Discussed likely tracheitis - possible causes include viral, allergens, or irritant exposure
- No signs of infection currently - temperature normal, glands not swollen, lung sounds clear
- Able to swallow without regurgitation, no signs of foreign body obstruction
- Anti-inflammatory chosen as safe for sensitive stomachs
- Clinic open Sunday 10am-12pm if concerns arise
- Owner travelling tomorrow; brother will be minding at same house
- Owner requested to be listed as primary vet in records