C09998626 / invoice 10000

lethargic and not eating or drinking
* not himself, has been unwell all day and saving to syringe water for him to drinking and appears very lethargic
* owner very concerned, was in the other week with vomiting and D+, has had some vomiting also

PRESENTING/OWNERS CHIEF COMPLAINT: ()

Consult Nurse: ()

History:
EDDU ()
V+ or D+ ()
Diet: ()
Vaccinations: ()
Preventatives; 
Worming: ()
Heartworm: ()
Flea & Tick: ()
Current Age: ()
Current Medications: ()
Behaviour Concerns: ()
History: ()

Physical Exam:
Attitude; ()
Behaviour: ()
HR: (); RR: ();  T: (); MMC: (); CRT: ();
Hydration: normal
BCS: ()/9
EENT: (eyes clear, no evidence of conjunctivitis, no discharge or blephrospasm); (no swelling or discharge to the external ear canal, ear pinnae clear); (no nasal discharge); () dental disease
Cardiac: (normal rate and rhythm, no murmurs on auscultation)
Resp: (normal rate, normal clear sounds auscultated in all lung fields)
Abdo: (comfortable on abdominal palpation, no palpable abnormalities)
Urogenital: ()
Integument: (no external parasites noted; no erythema or pruritis)
Neuro: (proprioception NAD; NSF)
Musk: (ROM in all joints NAD; no abnormalities on palpation)
Ln's: (Peripheral LN's WNL)

Client Communication from Consult Nurse:
()

Client Communication from Vet:
()

Laboratory/Imaging:
PreGA bloods = CBC / Chem ()
Hw test = ()
Abnormalities: ()
Veterinarians interpretation / summary of findings: ()

Assessment/Problem List:
()

Ddx:
()

Prognosis:
(Good, Fair, Guarded, Grave, Hopeless)

Treatment:
Medications: Drug name, mg/Kg or mg dose, volume/tablets given ()

Client Communication from Vet:
()

Plan:
Progress examination in () 

Internal treatment plan Comms:
()

Follow  up notes:
()              
Follow up phone called for for () days                                                       

lethargic and not eating or drinking
* not himself, has been unwell all day and saving to syringe water for him to drinking and appears very lethargic
* owner very concerned, was in the other week with vomiting and D+, has had some vomiting also

PRESENTING/OWNERS CHIEF COMPLAINT: ()

Consult Nurse: (NS)

History:
EDDU (up until today yes - hasn't eaten and has syinged some water
V+ or D+ (- had frothy V+ yesterday but nil today; stools have been firm since visit on 24/02 and been on Prokolin)
Diet: (chicken and/or wet food)
Vaccinations: (C5 UTD)
Preventatives; 
Worming: (Simparica Trio UTD)
Heartworm: (as above)
Flea & Tick: (as above)
Current Age: (1y 9m)
Current Medications: (Prokolin but hasn't had it today)
Behaviour Concerns: (nil)
History: (gastro upset 24/02 - had improved since then)

Physical Exam:
Attitude; (BAR)
Behaviour: (friendly)
HR: (120); RR: (36);  T: (38.1); MMC: (pink); CRT: (<2s);
Hydration: normal
BCS: (5)/9
EENT: (eyes clear, no evidence of conjunctivitis, no discharge or blephrospasm); (no swelling or discharge to the external ear canal, ear pinnae clear); (no nasal discharge); () dental disease
Cardiac: (normal rate and rhythm, no murmurs on auscultation)
Resp: (normal rate, normal clear sounds auscultated in all lung fields)
Abdo: (comfortable on abdominal palpation, no palpable abnormalities)
Urogenital: (NAD)
Integument: (no external parasites noted; no erythema or pruritis)
Neuro: (proprioception NAD; NSF)
Musk: (ROM in all joints NAD; no abnormalities on palpation)
Ln's: (Peripheral LN's WNL)

Client Communication from Consult Nurse:
()

Client Communication from Vet:
(Disc about diet
Dics about dental
Disc about GI indiscretion)

Laboratory/Imaging:
PreGA bloods = CBC / Chem (11)
Hw test = (Negative)
Abnormalities: (Mild reticulocytocis: 171.6  {10.0 - 110.0 K/µL} , associated with elevated MPV 14.3  {8.7 - 13.2 fL} and slighlty elevated ALT : 206   { 10 - 125 U/L} 
Veterinarians interpretation / summary of findings: ALT elevated alone probably due to cholestase secondary to anorexia. The reticulocytes elevation is due to mild blood loss (no anemia but dehydration might mask this), probably due to irritation of GI tract but DDx is open, need to be recheck in 2 weeks to see if improvement )

Abdominal radiographs: Aeric area in the stomach  bu otherwise WNL, GI is pretty empty 

Assessment/Problem List:
(- Nausea
- Anorexia intermittent
- Mild dehydration)

Ddx:
(GI indiscretion,
+/- oesophagus irritation)

Prognosis:
(Fair)

Treatment:
Medications: Drug name, mg/Kg or mg dose, volume/tablets given ()
Prevomax: 0.56 ml SC
Cerenia 16mg: Give 1 tablet PO SID start tomorrow for 2 days
Ondansetron 4mg: Give HALF  tablet PO BID for 4 days, start tonight
Stra him on Biome diet for a few days

Client Communication from Vet:
(Need to have a fix diet, we need to offer him food and stop changing
Offer him the same food for 3 days, and as long as we is bright, we need to not feed him a different diet until he eats, he can go several diet without eating )

Plan:
Progress examination in (7 days or sooner if he doesnt feel better) 
Recheck bloodwork in 1-2 weeks, 
When he feels better, hopefully net week, we can book a dental for him
Might need sucralfate when he stops vomiting to help his throat irritation

Internal treatment plan Comms:
()

Follow  up notes:
()              
Follow up phone called for for () days                                                       

unwell, didnt eat much yesterday and was lethargic last night 
had one diarrhoea in am otherwise no more and no vomiting

PRESENTING/OWNERS CHIEF COMPLAINT: ()

PRESENTING/OWNERS CHIEF COMPLAINT/REASON FOR VISIT
Charlie presented for being unwell. He did not eat much yesterday, was lethargic last night, and had one episode of diarrhoea this morning. The owner reports he has been generally 'off' with an intermittent appetite for the last week.

Consult Nurse
Maddie

History
EDDU: Inappetence for the last week, with no food consumed yesterday. Decreased water intake over the last 24 hours. One episode of diarrhoea this morning.  
Vomiting/Diarrhea: One episode of bright orange, wet diarrhoea this morning. Intermittent softer stools over the past week. One episode of vomiting bile approximately 1 week ago. The owner notes he occasionally heaves and brings up white, frothy material.  
Diet: A mixture of Eureka brand food (various proteins) and human roast chicken. The owner recently changed the type of roast chicken given.  
Vaccinations: Last C5 vaccination was on 12/09/2025. Next vaccination is due in September 2026.  
Preventatives:
-   Worming: Receives Simparica monthly.
-   Heartworm: Receives Simparica monthly.
-   Flea & Tick: Receives Simparica monthly, last given at the beginning of this month.
Current Age: 1 year, 8 months.  
Current Medications: None.  
Behaviour Concerns: Has been more clingy and resting on the owner's lap for the last couple of days.  
History: This is a recurring issue, with a similar episode about a month ago and another in September. He is a fully indoor dog. The owner has noted him dragging his bottom.

Physical Exam
General Appearance: Bright, Alert, and Responsive;  
Behaviour: Initially shaking but relaxed during the examination.  
Vitals: Heart Rate: 120; Respiratory Rate: 32 ; T: 38.5¡C; Mucous Membrane Colour: Pink and moist; Capillary Refill Time:  <2S
Hydration: normal  
Body Condition Score: 5/9  
Eyes, Ears, Nose, Throat: eyes clear, no evidence of conjunctivitis, no discharge or blephrospasm; no swelling or discharge to the external ear canal, ear pinnae clear; no nasal discharge; Mild dental calculus present.  
Cardiac: normal rate and rhythm, no murmurs on auscultation  
Resp: normal rate, normal clear sounds auscultated in all lung fields  
Abdo: Initially tense but relaxed on palpation. The intestines feel somewhat fluid-filled ('squelchy'). The abdomen was comfortable on palpation with no palpable abnormalities.  
Urogenital:  NAD
Integument: no external parasites noted; no erythema or pruritis  
Neuro: proprioception No Abnormalities Detected; No Significant Findings  
Musculoskeletal: Range of Motion in all joints No Abnormalities Detected; no abnormalities on palpation  
Lymph Nodes: Peripheral Lymph Nodes Within Normal Limits

Client Communication from Consult Nurse
No specific communication recorded.

Client Communication with Vet
The physical examination findings were discussed with the owner. It was explained that Charlie's signs are most consistent with dietary-induced gastroenteritis, possibly with a component of mild pancreatitis related to a recent change in the roast chicken he is fed.  
  
Recommendations for outpatient management were made, including an anti-inflammatory, an appetite stimulant, and probiotics to support his gut health. The owner was advised that if Charlie does not show improvement within 48 hours (e.g., continued inappetence), he would need to be admitted for intravenous fluids and further diagnostics like imaging.  
  
A discussion was had regarding the mild calculus on his teeth. A professional dental scale and polish under general anaesthetic was recommended for the future, once he has recovered from the current issue. The owner understood the importance and agreed to organise this at a later date.  
  
The owner was given a cost estimate of $282.35 for the consultation, in-clinic injection, and take-home probiotic paste. The owner accepted the plan and consented to treatment.



Assessment/Problem list
-   Acute gastroenteritis, likely secondary to dietary indiscretion.
-   Suspected mild pancreatitis.
-   Inappetence, lethargy, and dehydration risk.
-   Mild dental calculus.

Treatment
Medications: Prevomax (maropitant) injection administered for anti-nausea and appetite stimulation.

Plan
-   Administer Pro-Kolin paste: 3 mL orally twice daily to help bind stools and provide probiotics.
-   Administer Children's Panadol (1 month-1 year formulation): 0.8 mL orally twice daily for 5-7 days for pain relief.
-   Discontinue feeding any human food, including roast chicken, and stick to his regular diet.
-   Monitor appetite, hydration, and stool consistency closely.
-   A faecal sample pot was provided. The owner was instructed to collect a sample and bring it in for analysis if there is no improvement.
-   Recheck examination advised if no improvement within 48 hours.
-   Once fully recovered, schedule an appointment for a dental scale and polish under general anaesthesia.

Internal treatment plan Comms
Requested Pro-Kolin paste and Prevomax injection for the patient.

Follow up notes
Monitor for improvement. If no improvement in the next 2 days, the owner is to return to the clinic with a faecal sample for testing. The next visit will be for a dental procedure once he has recovered.  
Follow up phone call for: 2 days