C09991289 / invoice 10000

SUBJECTIVE:Presenting Concerns:  George presented for a recheck examination. He was seen 2 days ago for what was thought to be a torn toenail but was acting unwell. He has continued to vomit over the past 2 days despite treatment and is reported to be hiding in the bedroom and is duller than normal. The owner reports he has been unwell since Friday morning.    Historical Conditions:-   History of calcium oxalate uroliths.-   Has had a perineal urethrostomy surgery in the past.-   A urinalysis performed 2 days ago showed glucose in the urine.  V/D/C/S:-   Has been vomiting over the past 2 days despite treatment.  Drinking/Urination:-   Urination is reported to be fine.  Current Medications:-   No current medications reported.  Additional Information:-   The initial concern 2 days ago of a torn toenail was found to be foreign material on the foot.  OBJECTIVE:Mentation: Dull  BCS: --/9  T: 38.2°C  P: 116  R: 24  MM: Pink, tacky. CRT < 2sec.  Hydration: Mildly dehydrated    Emotional Assessment: Dull and not himself. He resisted the blood draw. Sedation was administered for the ultrasound.    Eyes: Clear. No discharge or erythema OU.  Ears: Clean with no discharge or erythema AU.  Nose: Clear, moist without discharge.  Throat: No inducible cough upon tracheal palpation; no palpable masses.  Oral: Calculus and gingivitis absent. No masses or other lesions.  Cardiovascular: No murmurs or arrhythmias, strong synchronous pulses.  Respiratory: Normal bronchovesicular sounds bilaterally.  Abdominal: Severe pain (rated 3 out of 4) on palpation. The abdomen is tense, particularly in the cranial segment.  Lymph Nodes: No peripheral lymphadenopathy.  Integumentary: No evidence of ectoparasites, full coat with clear skin.  Neurologic: No ataxia, normal mentation.  Musculoskeletal: No abnormalities found with the limbs.  Urogenital: The perineal urethrostomy stoma appears normal.  Rectal: Not performed.    Point of Care Diagnostics:-   In-house Bloodwork: Results were within normal limits. Electrolytes are stable.-   Blood Gas: Normal.-   Canine Pancreatic Lipase test: Negative.-   Urinalysis: Specific gravity 1.008. pH 6. The dipstick was negative for blood, urobilinogen, bilirubin, protein, nitrite, glucose, ketones, and leukocytes. The urine was light yellow and clear. No crystalluria was observed on sediment examination.-   Abdominal Ultrasound: The patient was sedated with butorphanol at 0.02 mg/kg IM and medetomidine at 10 mcg/kg IM. Findings include:-   Liver: Isoechoic to the spleen.-   Gallbladder: Anechoic contents with a small amount of sludge.-   Stomach: Contained ingesta with a uniform wall thickness of approximately 4 mm.-   Spleen: Normal echotexture and echogenicity.-   Kidneys: The left kidney measured 4 cm in longitudinal section with normal corticomedullary distinction and a normal renal pelvis.-   Adrenal Glands: The left adrenal gland was within normal limits, measuring 4 mm. The right adrenal was not definitively visualized.-   Bladder: Contained anechoic urine with normal walls and bladder neck.-   Prostate: Within normal limits.-   Pancreas: The pancreas was visualized and appeared slightly more prominent than normal. There were no definitive signs of pancreatitis, such as hypoechoic changes, surrounding hyperechoic mesentery, or fluid.-   Abdomen: No free fluid was detected.  ASSESSMENT:Suspected mild pancreatitis – This is suspected based on significant clinical signs including severe abdominal pain, lethargy, and vomiting. Ultrasound findings revealed a slightly prominent pancreas, which may support this suspicion, although there were no definitive ultrasonographic signs of pancreatitis and the canine pancreatic lipase test was negative. The etiology is unknown.    Resolved glucosuria and hyposthenuria – A repeat urinalysis today was negative for glucose, indicating the previous finding has resolved. The urine specific gravity of 1.008 demonstrates an ability to dilute urine.  PLAN:Medications/Treatments:-   Maropitant was administered at 1 mg per kg SQ for nausea.-   Metoclopramide was administered at 0.5 mg per kg SQ as a prokinetic.-   The patient was actively warmed following sedation-induced hypothermia (temperature dropped to 36.5°C) and placed in a warm cage.-   Discharged with the following oral medications:    -   Metoclopramide: 0.5 mg per kg to be given BID.    -   Paracetamol: 10 mg per kg to be given BID for pain management.    -   Losec (omeprazole): To be given SID.  Diet & Feeding Recommendations:-   Recommended feeding small, frequent meals.-   Advised to provide a small meal late in the evening before bed.  Additional Discussion:-   The owner was updated by phone throughout the day regarding examination findings, diagnostic results, and the treatment plan.-   It was discussed that bloodwork was stable and hospitalization with IV fluids was not necessary at this time.-   The owner is to monitor George at home and to return if his signs worsen.    Vital Signs