C09982502 / invoice 10000

Reason: V+HISTORY:Molly presented for acute onset vomiting and lethargy. The owner reported the first vomit occurred around 4 pm today in the car. There have been several vomits since, initially containing food and a partially-eaten dental chew, and now consisting of bile. The last vomit was at approximately 6:45 pm. One episode of diarrhoea was reported around 5:30 pm. Molly is described as markedly lethargic and is not interested in food, which is abnormal for her.Dietary history includes a sardine yesterday (has had before but not recently) and a larger-sized dental chew today, half of which was vomited up. There is a possibility of foreign body ingestion as she is known to eat things from the floor and regularly ingests sand at the beach. Access to toxins such as toads, snakes, or human medications is considered unlikely by the owner.Current meds: noneUTD with FTW and vacc EXAMINATION:QARHR 88RR 32PL ssfp MM pink wet  CRT 1.5sT 39.1Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normallyGastrointestinal:- Abdominal: no detectable pain on abdominal palpation- Rectal: brown liquid d+ Not interested in treat - OR very unsual for her. PROBLEM LIST:- Vomiting (acute)- Diarrhoea (single episode)- Lethargy- InappetenceDIFFERENTIAL DIAGNOSIS/DIAGNOSIS:- Gastroenteritis (e.g., dietary indiscretion, infectious)- Gastrointestinal foreign body obstruction- Underlying systemic diseaseDIAGNOSTICS:NoneASSESSMENT:Molly, a 5-year-old dog, presented with acute vomiting, lethargy, and a single episode of diarrhoea. Examination revealed no significant abnormalities apart from lethargy and inappetence. Key differential diagnoses include acute gastroenteritis, foreign body ingestion, or an underlying systemic issue. Given the clinical signs, symptomatic treatment was initiated with a plan for further diagnostics if signs do not resolve or worsen.TREATMENT:Maropitant 1mg/kg sc  injection administered for anti-nausea effects.PLAN:Home into owner's care.Monitor for further vomiting, changes in demeanour, or worsening of clinical signs.If vomiting persists despite the maropitant injection, or if she is not eating by tomorrow morning, re-presentation is recommended for further diagnostics, likely including radiographs and/or blood tests.The owner can re-present within 24 hours without an additional consultation fee.Transfer to Primary Vet for follow-up if needed.CLIENT COMMUNICATION:Discussed the likely causes of Molly's symptoms, including gastroenteritis and the possibility of a foreign body. Recommended radiograph - declined.  Explained the treatment plan, which involves an anti-nausea injection  to make her more comfortable and to assess her response. Advised the owner on signs that warrant immediate re-presentation, such as continued vomiting, worsening lethargy, or refusal to eat by the next morning. Discussed the plan for further investigation (X-rays, blood tests) if she does not improve.    Vital Signs    Weight: 14.6;