C09970380 / invoice 10000

Reason: Went Limp - EpisodeHISTORY:Presented for lethargy, inappetence, and one episode of vomiting today. The owner reports Dora did not eat dinner last night or breakfast this morning. She began to eat today, then stopped and appeared to collapse. The owner described her as feeling hot and appearing dehydrated. She has been lethargic, sleeping a lot, and unusually cuddly today. A further episode of vomiting was noted a few days ago, which is unusual. No diarrhoea reported. Possible ingestion of a tissue with cocaine on it last night was mentioned, but this is unconfirmed. A recent dietary change was made two days ago, with the introduction of raw lamb liver.Current meds: NilProphylaxis: Not discussedPre-existing conditions: No known murmurs or other significant pre-existing conditions. Triage:HR: 92RR: 20Temp: 38.5Mm: pink and moistCrt: <2Mentation: BAR EXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): EuhydratedCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronous. No murmurs auscultated.Respiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: Mentation appropriate. Plr positive , menace positive, palpebral positive . No abnormal strabismus or nystagmus positional or otherwise noted. Normal facial sensation and motor. Normal facial symmetry. Normal gag reflex. No neck pain. CPs and withdrawals present in all limbs. Patella reflexes intact. Cutaneous trunci reflex WNL. Strongly ambulating with no observable ataxia. Normal posture. Perineal reflex WNL. Adequate anal tone. Full exam not performedMusculoskeletal: Strongly ambulating x4. Adequate range of motion in joints, no overt swelling or painGastrointestinal:Oral: mild dental diseaseAbdominal: Abdomen soft, non painful on palpation. No organomegaly or fluid wave appreciatedRectal: not performedUrinary: no significant findingsReproductive (incl ext genitalia): no significant findingsIntegument/Ears: clean and shiny haircoat. No skin masses of lesions noted. No fleas or flea dirtLymph Nodes: peripheral lymph nodes palpable < 1cmEyes: no significant findings  PROBLEM LIST:1. Acute lethargy/collapse2. Vomiting3. Inappetence4. Possible toxin ingestion (cocaine)5. Recent dietary change DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:1. Mild gastroenteritis secondary to dietary indiscretion/change.2. Effects of possible cocaine ingestion (considered less likely given normal vital signs).3. Syncope event (less likely, no evidence of underlying cardiac disease). DIAGNOSTICS:Nil ASSESSMENT:Dora presented for acute lethargy and vomiting. Examination findings and vital signs are within normal limits. The clinical signs are most likely attributable to a mild, self-limiting gastroenteritis, possibly secondary to a recent dietary change (introduction of raw lamb liver). While possible cocaine ingestion was reported, the lack of tachycardia, hyperthermia, or agitation makes this a less likely cause of the current clinical signs. An anti-nausea injection was offered but declined. A plan was made to monitor at home. TREATMENT:Nil administered in clinic. PLAN:Monitor at home for any recurrence of vomiting, lethargy, or development of new clinical signs.Continue with normal diet and observe appetite.Re-present for re-evaluation if clinical signs worsen or fail to resolve. CLIENT COMMUNICATION:Discussed the examination findings, which were all normal. Explained that the most likely cause is a mild gastrointestinal upset due to the recent dietary change. Discussed that signs of significant cocaine toxicity (high heart rate, high temperature, agitation) were not present, making it an unlikely cause for the signs observed today. The option of an anti-nausea injection was offered but declined. Advised to monitor at home and to return if there is any concern. The option of a urine drug test was discussed but deemed unnecessary at this stage as it would not alter the current management plan. Advised that cocaine may be detectable in urine for up to two days if testing were required later.    Vital Signs