C09971001 / invoice 10000

Reason: Y - Chased Hose, Susp Aspirated MUZZLE Triaged TYLHISTORY:Roy presented for abnormal behaviour, vomiting, and abnormal breathing following an incident at a children's party today. The owner reports that Roy was sprayed with a hose and may have ingested a large volume of water, which caused coughing. This was not evident on consultation. There is also potential ingestion of an unknown quantity of chocolate mud cake, most likely without any artificial sweeteners.. The onset of clinical signs was approximately 4-5 hours prior to presentation. Roy vomited a few times and was observed to be shaking, salivating, and acting uncomfortable. On presentation Roy is BAR and slightly aggressive, with normal breathing rate and effort.Current medications: None.Prophylaxis: On NexGard for parasite control. The last dose was administered last month, and the next dose is currently due.Pre-existing conditions: No significant past medical history.Access to toxins eg. Rodenticide:- Potential ingestion of chocolate mud cake today, amount unknown. The calculated dose is below toxic levels.TRIAGE:HR: 130RR: WNLTemp: 37.8Mm: pink Crt: <2 secondsMentation: BAREXAMINATION:Body Condition Score: 4/9Pain Scale (0-4): 0Hydration status (%): <5% dehydrated Cardiovascular: Normal heart rate with bounding pulses. No arrhythmia detected on auscultation. Respiratory: Thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal discharge. No crackles or increased lung sounds detected. Tracheal pinch negative.Neurological: Neurologically no significant findings, no cranial nerve or proprioceptive deficits/gait detected. No nystagmus or facial nerve deficits noted. Tremors are attributed to discomfort rather than neurological signs and not noted on presentationMusculoskeletal: Ambulating normally, though posture appears rigid which resolves after interacting with the patient. No palpable neck, spine, limb or joint pain.Gastrointestinal:- Oral: no significant findings, no mouth pain- Abdominal: Abdomen is tense but non-painful on deep palpation. No evidence of pancreatitis. Normal gut sounds.- Rectal: Performed. Firm faeces palpated.Urinary: no significant findingsReproductive (incl ext genitalia): no significant findingsIntegument/Ears: Significant gunk noted in the ears, particularly the right ear. No odour detected.Lymph Nodes: no significant findingsEyes: no significant findings, no nystagmus notedPROBLEM LIST:- Potential chocolate toxicity / gastroenteritis- Potential aspiration from water ingestion- Otitis externaDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:- Potential Chocolate Toxicity / Gastroenteritis: Suspected toxicity versus dietary indiscretion. The clinical signs of vomiting and discomfort are consistent with both possibilities.- Potential Aspiration Pneumonia: Risk of aspiration from drinking from a hose. Currently no clinical signs are present.- Otitis Externa: Debris noted in ears on examination.DIAGNOSTICS: Not applicableASSESSMENT: Roy presented for vomiting, shaking, and discomfort after potentially ingesting chocolate cake and a large volume of water from a hose at a party. The primary concerns were for chocolate toxicity, aspiration pneumonia, and acute gastroenteritis. Examination revealed Roy to be bright and alert but uncomfortable with bounding pulses. His abdomen was tense but not painful, and his lungs were clear on auscultation. The calculated dose of potential chocolate ingestion was determined to be below toxic levels. The risk of aspiration pneumonia is present, but Roy currently shows no clinical signs with clear thoracic auscultation. Debris was noted in his ears, consistent with otitis externa. Monitoring with hospitalization, fluids and blood gas analysis was recommended however declined by the owner. TREATMENT:- Maropitant 1mg/kg administered subcutaneously for anti-emesis. @1645- Methadone 0.2mg/kg administered subcutaneously for analgesia. @1645PLAN:- Monitor for signs of chocolate toxicity such as tremors, seizures, ongoing vomiting, or lethargy.- Monitor for signs of aspiration pneumonia including coughing, lethargy, inappetence, or increased respiratory rate/effort.- Advised to offer small, frequent meals starting with a quarter of his normal food, and to gradually reintroduce his normal diet over the next few days.- Recheck with the primary care veterinarian next week is recommended to ensure no delayed signs of aspiration pneumonia develop and for assessment of his ears.- Advised to clean ears at home with existing ear drops.CLIENT COMMUNICATION:The owner was educated on the clinical signs of chocolate toxicity (tremors, neurological signs) and aspiration pneumonia (coughing, breathing difficulty) to monitor for at home. Advised against administering Previcox from another dog due to the risk of gastrointestinal ulceration, especially with vomiting. The owner was instructed on how to administer the ear drops by instilling them, massaging the base of the ear, and then allowing Roy to shake his head. Advised that there would be no charge for a re-presentation within 24 hours if concerns persist. Advised owners if any deterioration then to represent for reassessment. To represent to Animal Emergency Service or primary care veterinary clinic as soon as practical if patient noted to deteriorate.    Vital Signs