C09994729 / invoice 10000

LETHARGIC AND LABOURED BREATHING & NOW OFF FOOD
is insured

Verified: NO

HISTORY
Presenting for: Luna, a 4-year-old female dog, presented for lethargy and avoidance behaviour since approximately 1:30pm today.
Diet:
- Decreased appetite - husband attempted to feed her today and she did not eat
- Avoiding food, which is very unusual for her
Drinking/Urination:
- Had a drink before leaving for the appointment
V/D/C/S:
- No vomiting or diarrhoea
- No coughing
Current Meds:
- Flea and tick prevention up to date (administered 1 week ago)
- Vaccinations up to date (due for next vaccination in 2 weeks)
Lifestyle Risk Factors:
- Lives on rural property with cattle
- Has been outside
- Property has snake repellents and owners have never seen snakes
- Household includes 2 small children
Other:
- Very unusual behaviour - normally active and playful, especially with ball
- Has been lying around and avoiding family members
- Online vet consultation via pet insurance noted lethargy and slow breathing

EXAM
Mentation: Lethargic
Behavioural: Very calm and lethargic for a Golden Retriever, though naturally a calm dog which makes assessment challenging. Not showing usual interest in meeting people.
Wt: 24.9 kg
T: 38.5°C
HR: 52, regular, no murmurs
R: 60, regular, clear lung sounds
MM: PP, moist <2
EENT eyes and ears clean and clear, teeth good
NEURO: menace, palpebral NAD, Pupils constricted
Abdominal: Some pain noted on palpation, soft on palp
Musculoskeletal: Slightly hunched posture indicating possible pain. Walking normally without lameness.

Diagnostics: Coagulation studies - normal. Full blood panel - all results normal including RBC and WBC counts.

ASSESSMENT
Lethargy and abdominal discomfort - DDx: musculoskeletal injury, unknown toxin ingestion, snake bite (less likely given normal coagulation studies and blood work)

PLAN
- Meloxicam 1.6 mL PO daily with food for 5 days (anti-inflammatory and analgesic)
- Rest for 5 days - no ball playing or strenuous exercise, gentle walks only
- Monitor and Contact clinic if condition worsens or fails to improve