C10027647 / invoice 10000

13/03/2026 
Reason/concerns:  V+ and D+ 

History:
4.1kg 
- Hx of V+ and D+ last month - had resolved until yesterday 
- Had D+ last night and V+ this morning - no blood, mucus in stool 
- Had access to succulent last night may have eaten (Jade plant) 
- Diet: crocodile mince + veggies 
- No access to other toxins 
- Mild reduction in appetite this morning, still eating then V+ up  
- Normal drinking and urination. 
- no other concerns at home 

Pre-exisitng Conditions / Medications: Nil 

Examine: 
Mentation: BAR
BCS:                           /9   
MM: Pink          
CRT: 1-2 seconds
HR:                    160         beats/min
RR:                             breaths/min
Temperature:      38.5        degrees Celsius

Ocular: No abnormalities noted on cursory examination of both eyes.
Oral/Dental stage: x  gingivitis and calculus observed. Gx/4 dental disease. 
Ears: No abnormalities noted on cursory examination of both ears.
Cardiovascular: No audible murmur or arrhythmia and no difficulty hearing the heart. HR = PR and no evidence of hypoperfusion.
Respiratory: Respiratory rate and effort considered normal for the patient.
Gastrointestinal: No pain on abdominal palpation. No masses or abnormalities palpated.
Integumentary: No significant abnormalities.
Musculoskeletal: Normal gait and strength noted. No evidence of lameness.
Urogenital: No significant abnormalities noted during routine physical examination.
Neurological: No evidence of neurological impairment or altered mentation. Detailed neurological examination not performed today.
Lymph nodes: Within normal limits for mandibular, prescapular and popliteal examination.

Problem List:

Patient Assessment: 

Diagnostics performed (i.e. bloods, radiographs/ultrasound, ear cytology, urinalysis):
- CRP  

Treatment with medication dose rates (if any):
- Charchol 
- Ondansatron 

Client Communication & Plan: 
- Monitor at home 
- Will call about results 
- Hilols z/d diet 
- avoid plants 


On-going medications required: Y/N (use prescription tab for further supply):

Next check up date: CP tomorrow