C10029216 / invoice 10000

11/03/2026 Revisit reason:check AG and ears 

History:
Has not been scooting 
O has not seen any head shaking 
O accdientally gave pre visit medication wrong- gave one traz last night and one gaba this 

O noted has been coughing for a day and a half 
hx of megoesophagus - eats on higher ground 
Has had hx of pneumonia - went to waves

Medications:gaba, traz

EDUF:normal
Mentation:BAR
BCS (0-5):      
HR: 112
RR: pant clear- no crackles/wheezes during ausc 
MM:  pm                
CRT: <2s
Temperature:
Dental Stage:
Any additional findings:

Assessment:
Resolved OE 
Could not perform AG safely due to inadequate previsit sedation- okay to monitor as scooting no longer present 

Coughing ddx: infectious, megoesphagus flare up, 
Discussed KC possibility - takes 3 weeks to recover
O has not seen him cough as much so would like to monitor any coughing. Will pick up AI for trial if not 

Treatment:
script for AI 7d if coughing persistent 

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

Plan: INI with coughing, revisit for bloods and thoracic xrays 
Monitor for lethargy , inappetance etc