C10027025 / invoice 10000

Reason: V+ & D++, Have Said Very Little We Can DoAppointment Notes: and likely referral to emergency but O not keen on that. Wanted appt for tomorrow but have stressed importance of IVF and hospital care which we cannot provide for long tomorrow either as only open 4hrs. No possibility of coming earlier.. BH(Daughter came in to get dog seen sooner @ 12:30pm)Pet Primary Diagnosis/Suspected Diagnosis/Location: acute gastroenteritisSuspect cause: open.Any other conditions being treated (if any): NILKnown health concerns: NILDate of first clinical signs (if known): 3 days ago.To be filled in prior to submitting claimAdditional notes can be added laterHISTORY:2x frothy vomits, 2x brown/bilious vomit3x diarrhoea, wateryOff food 3 daysHas been drinkingOccasional cough and sneeze.Goes for walks.Nothing unsual givenDIET: chicken necks, chicken loaf, mince, pro-biotic, coconut oil.VACCINATION STATUS: should be UTD with vaccines.PARASITE PREVENTION: monthly all-in-oneENVIRONMENT: not really an indiscriminate eater, no one away.EXAMINATION:MENTATION: QAR, normal mentationBEHAVIOUR: good girl.INTEGUMENT: no significant findingsEYES: no significant findingsEARS: no significant findingsORAL: no significant findingsLYMPH NODES: Submandibular, popliteal normalCARDIOVASCULAR: cardiac auscultation, femoral pulse normalRESPIRATORY: eupnoeic. nares, throat, lung auscultation normalABDOMINAL: palpation- mild generalised discomfort in abdomen.RECTAL: dark brown smear faeces in rectumUROGENITAL: no significant findingsMUSCULOSKELETAL: ambulatory x 4, no obvious lamenessNEUROLOGICAL: no obvious deficits presentedLABORATORY:Giardia test: negativeBiochem:Mild ALT, ALB and TBil elevationMild hypokalaemiaPlatelet clumping on blood smear confirmed.ASSESSMENT:Acute vomiting & diarrhoea. DDx- primary GI inflammation most likely (dietary, toxin etc), ddx- extra-GI causes.Options discussed:1) ideally fluids in hospital + supportive care2) oupatient treatmentO elected outpatient treatmentTREATMENT:Prevomax 1mg/kg SCPro-kolin paste at homeBland diet: chicken and rice PLAN:INI overnight and still unwell tomorrow, then definitely will need hospitalisation on fluids.    Vital Signs    Weight: 13;       MMColour: pk moist;       Temperature: 38.2;       HeartRate: 84;       BodyScore: 8;       RespirationRate: 16;       CRT: 2s;       

Reason: GroomingHEAD: 1/2 inch comb teddy face, leave eyelashes long   BODY/LEGS: 5fSHAMPOO: normalNice dogNails & Ears Done.    Vital Signs    

Reason: GroomingHEAD: 1/2 injch comb teddy face, leave eyelashes long   BODY/LEGS: 5fSHAMPOO: normalNice dogNails & Ears Done.    Vital Signs