C10032300 / invoice 10000

Reason: Lethargic Not Eating DrinkingTIME:HISTORY:Current meds: Prophylaxis: Pre-existing conditions: Access to toxins eg. Rodenticide: TRIAGE: HR: RR: Temp: Mm: Crt: Mentation: Pain Scale (0-4): Hydration status (%): EXAMINATION:Body Condition Score: Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4):  - Abdominal: no detectable pain on abdominal palpation, normal gut sounds- Rectal: no detectable abnormalities, faeces:  Urinary: NSFReproductive (incl ext genitalia): NSFIntegument/Ears: NSFLymph Nodes: peripheral lymph nodes normalEyes: NSFPROBLEM LIST: DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS: DIAGNOSTIC/MANAGEMENT PLAN: 1.2.3.4.    Vital Signs    Weight: 5.8;