C09985077 / invoice 10000

HISTORY:  Presented for vomiting over the last few hours. Owner reports multiple episodes of vomiting, with photos showing undigested food. No blood observed in the vomitus. This is different from previous episodes where blood was present. Seen by a regular vet yesterday, who noted no abdominal pain and expressed anal glands. Omeprazole was prescribed but not administered as Teddy was not eating. The owner administered a probiotic in water via a syringe, after which Teddy developed watery diarrhoea. Before the probiotic, faeces were normal.History of potential dietary indiscretion on Friday, guests were over. May have been given cucumber and a small piece of a chip. Wife reports he ate three pieces of sweet potato, which were visible in the most recent vomitus.Last ate and kept food down yesterday evening. The vomiting started yesterday afternoon. Drank a large amount of water at the vet clinic, which was unusual, and subsequently vomited the water at home. Owner notes he may have eaten grass on a walk. He is not eating today.Regular Vet: Seen yesterday. No abdominal pain on palpation. Anal glands expressed. Only omeprazole was prescribed. Double checked with owner no maropitant was given.  Current meds: omeprazole and pro-biotics Vaccination: UTD.Parasite Prevention: UTD.Pre-existing conditions: History of acute haemorrhagic diarrhoea syndrome hospitalized at GVHAccess to toxins eg. Rodenticide: none EXAMINATION:very BAR, jumping and wagging tail T 38.5 pink MM, mildly tacky, crt <2 Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): Mildly dehydrated. mildly tacky MM no skin tent Cardiovascular: 120 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 normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4):not graded- Abdominal: no detectable pain on abdominal palpation. - Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: Bright, alert, wagging tail. PROBLEM LIST:VomitingAnorexiaWatery diarrhoeaMild dehydrationHistory of dietary indiscretion DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:intra vs extra GITIntra: inflammatory (gastroenteritis, dietary indiscretion) vs infectious vs FB vs other secondary: pancreatitis vs endocrine (addisons) vs toxin vs renal/heptic vs other  DIAGNOSTICS:None performed options of CBC and biochem were given to the owner. Owner declined.  ASSESSMENT:Teddy presented for vomiting and inappetence. Examination is largely unremarkable apart from mild signs of dehydration. Abdomen is soft and non-painful. Given the clinical signs and history, gastroenteritis secondary to dietary indiscretion is suspected. A recurrence of his previous acute haemorrhagic diarrhoea syndrome is also a possibility. Blood work was offered but declined at this stage. Proceeding with symptomatic treatment. TREATMENT:  - Maropitant 1 mg/kg SC  PLAN:Home into owner's care.Monitor closely at home for ongoing vomiting, lethargy, or worsening diarrhoea.Offer a bland diet in small amounts tomorrow if no further vomiting.Reassessment recommended if vomiting continues despite the anti-emetic injection, or if he does not eat within 24-48 hours.Follow-up with regular veterinarian in 2-3 days for a check-up, or sooner if concerns arise. Further diagnostics such as blood work and imaging may be required if he does not improve. CLIENT COMMUNICATION:Discussed the examination findings and likely diagnosis of gastroenteritis. Explained that the anti-emetic injection should control the vomiting, but it treats the symptom, not the underlying cause. Advised that it can take some time to take effect. If he vomits again in a few hours hours post-injection, he should be reassessed. Advised on signs of deterioration requiring immediate veterinary attention: continued vomiting, profound lethargy, refusal to eat for >24-48 hours, or if he seems unwell. Discussed the plan for a bland diet and follow-up with their regular vet.    Vital Signs