C09988117 / invoice 10000

02/03/2026 Hx
Some vomiting on friday - bile vomits with some very small food particles. Through weekend continued to eat small amounts and drinking but less than usual. Seems sad but does have energy. 
Has been eating some food although very inconsistent - today not keen on food at all. Some vomits early this morning, no diarrhoea as yet. 
Should not have access to bins, food scraps or given any bones. Not a dog that chews on random objects. 
No other meds. 

Ex
QAR
gums pink slightly tacky (assume 5% dehydration)
Heart no murmur/arrhythmia  
Lungs wnl
Skin tent normal
abdo palp slightly tense - able to palpate. 
Increased GIT sounds both sides
BT 38.1

Ax
Gastroenteritis vs FB ingestion vs other

Px
Gave Os 2 options, admit for FB workup + stabilise or manage medically at home. Os opted to manage at home, gave cerenia injection SC and ondansetron BID to start tomorrow. INI and cannot start eating/drinking again then advised may need to spend day in hospital anyways to resolve dehydration. 

02/03/2026 O Called back later. Worried as hasn't eaten anything even treats. Not drinking either.
Discussed with JR.
Advised give ondans now. Monitor over the next hour-hour and a half.
INI BY 6-6:30pm go to GAE.

04/03/2026 Revisit 
No improvement with maropitant and ondansetron in regard to nausea - still grass eating and very reduced appetite 
Vomiting stopped
No diarrhea but very mucus stool with blood-tinged stool - sample brought in today 

Normal appetite: R/C adult kibble with 1/3 frozen chicken wing 
- no table scraps 
- no change in diet recently 
- not a known scavenger 
No previous hx of GIT issues - very social dog though 

PEx: 
QAR 
37.7 - very sore for temperature - did not do a rectal as response from temperature 
Pink, tacky, CRT2
Skin tent slightly delayed 
Femoral pulses fair 
HR 104bpm, no murmur or arrythmia 
RR clear lung sounds, normal effort 
LN wnl 
Abdominal palpation uncomfortable for palpation - no obvious FB palpated, increased gut sounds on auscultation 

IV catheter placed in cephalic 
Blood abnormalities: 
- Catalyst Pancreatic Lipase - <30 (0 - 200 U/L) 
- No other abnormalities on CBC or biochemistry 

PCV/TP: 44/60

Problem list: 
1. Haemorrhagic stool - digested blood 
2. Dehydration - 5-8% 
3. Reduced appetite + lethargy 

P: 
Sent to NC for IVFT and medication today - did include x-ray on estimate but pending bloodwork and response to fluid therapy may not need further work-up today 
Explained that the team at NC may not have time to imaging (May swap from x-ray to abdominal ultrasound pending inital response to tx today) 
Was told that she may need to be transferred to GAEC tonight 

04/03/2026 Diet - Turkey prime 100

04/03/2026 Day of hospitalisation: 1

Hx is on a dry dog food only and 1/3rd frozen chicken wing per night
O concern was they noticed carrots in stools - sloppy in consistency
off food,nausea and v+ (bile content)
thirst - nil and wouldnt drink for o
not interested in food or her dry chicken treat
no known access to change of food. does have a sensitive tummy (as per when she was a puppy). O keeps a strict diet plan for her as result of that hx.
has been v lethargic o feels - not wanting to ball play
has in the last few weeks been cooling herself down in the neighbours fish pond - new event
Has been unwell since Friday
Had inj maropitant Monday and anti-nausea since Monday (ondansetron)




Reason for Hospitalisation: in appetance and abnormal stool
There is no hx of d+ and no known blood content to the stool when discussed further with o

Vet: ras
Nurse: Maggie
Morning assessment: comfortable abdomen with normal GI sounds
quiet demenour
3-5% dehydration as assessed
Client communication & cost updated AM - estimated via OG
Plan for the day: assess blood work and consider ddx
IV fluid therapy: 1.5x M for 4h Ho period
Medications: nil additional
Diagnostics and summary of results: normal CBC
normal biochemistry
normal CRP
BLC = 49 (consideration for completeness to do a stimulation test)

Run baseline cortisol - done
CRP - normal
Collect urine - normal concentration and pH


Consider u/s and imaging pending (not considered urgent at this time - although o is very concerned)

Afternoon assessment: eating well for us and BAR
does sit with low HR and low T for patient in Ho

Client communication & cost updated PM  - discussed the hx and p/e and bloods
suggested likely dx CIE and diet sensitivities but can not exclude addison's without further testing

Working diagnosis: acute on chronic intestinal enteropathy/diet sensitivity +/- hypoA
PLAN: return for an ACTH stim and reassess tomorrow
symptommatic tx in the interim as is stable and eating well in Ho with low level evidence for hypoA


04/03/2026 Appetite - Ate 2-3 pieces when hand fed

04/03/2026 Diet - Turkey prime 100

04/03/2026 Urinalysis 
Collection method: free catch @4:30pm by Maggie 
Colour: dark yellow
USG : 1.053
pH : 7.5
Protein : trace
Blood : neg
Glucose : neg
Ketones : neg
Bilirubin : small-moderate 
Sediment : {__}
Assessment: {__}
Plan: {__}
Owner contacted with results: {__}