C10001760 / invoice 10000

Reason: Not being himself, pale, shaking.TIME: 11:33HISTORY: Presented for being unwell, pale, and shaking since 09:30 this morning. Retching clear, foamy liquid over 10 times, without food. Progressively worsening grunting/coughing sounds since yesterday, now a hacking cough followed by a terminal retch producing fluid. Reduced appetite for the past 2 days; did not eat this morning. No prior vomiting or regurgitation. No diarrhoea observed. Attended doggy daycare last week.Current meds: None.Prophylaxis:  Up to date with vaccinations. Yearly tick and flea injection is current. Received an all-wormer tablet last week.Pre-existing conditions:  None reported.Access to toxins eg. Rodenticide: No known access. Primarily an outdoor dog during the day, crated inside at night. Does not chew or ingest non-food items.TRIAGE: HR: 92 bpmRR: 36-44 bpm, with slightly increased effortTemp: 39.3°CMm: Initially pale pink, improved with timeCrt: <2sMentation: QuietPain Scale (0-4): 0/4Hydration status (%): Clinically hydrated, mucous membranes moistEXAMINATION: Body Condition Score: 4/9Cardiovascular: No murmur or arrhythmia. Femoral pulses normokinetic and synchronousRespiratory: thoracic auscultation - lung sounds are slightly harsh bilaterally. Dry cough present and positive tracheal pinch. Normal rate and effort. No nasal or ocular discharge.Neurological: Normal mentationMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint pain Gastrointestinal:- Abdominal: no detectable pain on abdominal palpation, no mass effect or fluid wave.Urinary: NAD outwardlyIntegument/Ears: No skin tentLymph Nodes: peripheral lymph nodes normal Eyes: NADDIAGNOSTICS:Thoracic and abdominal radiographsIV cannula placementBlood testsPCV TP:PCV: 47%, within normal limitsTP: 82 g/L, mildly elevatedSerum: ClearInterpretation: Mildly elevated total protein may be consistent with dehydration Blood Gas Analysis Results venouspH: 7.34pCO2: 38pO2: 37Na+: 141K+: 3.9Cl-: 111Ca++: 1.22Glu: 4.4Lac: 3DerivedBE(B): -5.3AG: 13HC03c: 20.5HCt: 48%Interpretation:Mild metabolic acidosis with a normal anion gap, likely secondary to gastrointestinal bicarbonate loss from vomiting/retching. Mild hyperlactataemia. Normoglycemic -Spot glucose 3.9.Repeat spot blood glucose: 5.6 (after eating)Radiographs:Thoracic:Extra-thoracic structures: No significant abnormalitiesDiaphragm: IntactPleural space: No air or fluidLarge airways: No significant abnormalitiesPulmonary: Consolidated right middle lung lobe with an alveolar-interstitial pattern.Cardiac: Normal size and outlineOesophageal: no air or foreign body presentAbdominal:Extra-abdominal structures: no significant abnormalitiesSerosal detail: goodLiver/spleen: normal size and outlineGIT: No obvious radiopaque foreign body, or intestinal gas dilation (< height of L2 in dogs, L4 in cats)Kidneys:Left: normal size and outlineRight: difficult to visualise completelyNo obvious renolithsBladder/Prostate: bladder present, no obvious radiopaque urolithsInterpretation:Chest radiographs show changes consistent with aspiration pneumonia in the right middle lung lobe. Abdominal radiographs are within normal limits.Assessment / Differential diagnosisThe primary concerns are the cough, retching of clear foam, positive tracheal pinch, and lethargy. The clinical signs are highly suggestive of infectious tracheobronchitis (kennel cough), especially given the history of attending doggy daycare last week. The severity of clinical signs (lethargy, reduced appetite, frequency of retching) raises concern for a more severe presentation of kennel cough or a secondary complication, such as aspiration pneumonia. While vitals are largely stable, the pyrexia and increased respiratory effort are noted.PROBLEM LIST: - Coughing and retching- Pyrexia- Lethargy and inappetence- Increased respiratory rate and effort- Aspiration pneumonia (right middle lung lobe)ASSESSMENT:Infectious tracheobronchitis (kennel cough) complicated by secondary aspiration pneumonia.Initial low normal blood glucose improved after eating small amount of food. TREATMENT:Maropitant 1mg/kg SC --> Cerenia 12mg PO Q24 x 2 days Start tomorrow nightButorphanol 0.3 mg/kg IV and Medetomidine 3 mcg/kg IV for sedation for radiographs. Reversed with atipamezole 0.02ml IMCommenced amoxicillin 22 mg/kg IV --> Amoxyclav 125mg PO Q12 x 7 daysTramadol 2mg/kg ( 12.5mg) PO Q8-12 PRN start tomorrow morningCLIENT COMMUNICATION:Discussed clinical findings and assessment with the owner. Explained the signs are typical for kennel cough, but the severity and imaging findings confirm a secondary aspiration pneumonia. Discussed the recommendation for hospitalisation for IV fluids, IV antibiotics, and supportive care. Owner consented to initial diagnostics, anti-emetic injection, and hospitalisation.Updated on rad findings - kennel cough with secondary aspiration pneumonia. Updated on glucose concerns - normalised. Suitable for discharge home. Explained at home care. PLAN:TGH for strict rest and monitoring.    Vital Signs    Weight: 5.7;