C10003900 / invoice 10000

REASON: Lethargy, ataxia, and urinary incontinence.HISTORY:Presented this morning after being found lethargic and unwilling to exit his crate. Upon rising, he was noted to be unsteady on his feet and was found lying in pools of urine, consistent with urinary incontinence. Since arrival, the ataxia has improved, and the urinary dribbling has resolved. He is now more alert and steady.Eating and drinking as normal prior to today.No vomiting or diarrhoea.Previous relevant medical history:Known to ingest foreign objects, specifically socks. Has previously passed socks without surgical intervention. No other underlying health concerns.Access to toxins:No known access to toxins, including macadamia nuts or common household medications such as ADHD medication, Valium, or muscle relaxants. He did not go for a walk off the property recently.Subjective:BARObjective:Temp: 39.4°C    MM: pink   CRT: <2s   HR: 72 bpm   FP:   S&S   RR:  pant BCS: 8/9Weight: 45 kgPain Score (0-4): 0/4CV: No heart murmur or arrhythmia noted. Femoral pulse strong & synchronous.RESP: Normal bronchovesicular sounds, normal resp rate/effort.GIT: Soft and comfortable on palpation. No obvious fluid wave no organomegaly. U/G: NAD. Rectal exam not performed.Neuro: Generalised ataxia noted, but improving. No other neurological deficits observed. CN intact. CP and withdrawal present. Dribbling urine in consult.M/S: Able to right, rise and ambulate on all fours. No M/S pain evident on exam. A very slight, non-repeatable reaction was noted on palpation of the mid spine.Integ: Normal skin turgor.Ophth: No ocular discharge, pupils equal & reactive, clear corneas & lenses.Lymph Nodes: No evidence of peripheral lymphadenopathyINTERNAL LABORATORY:Urinalysis in houseMethod: free catchWet Prep: A urine drug screen was performed and was negative for all substances, including THC.PROBLEM LIST:Primary problem: Ataxia and urinary incontinenceAdditional problem(s): History of foreign body ingestion (pica)ASSESSMENT:Rory presented for acute onset lethargy, ataxia, and urinary incontinence. On presentation, he was pyrexic but otherwise haemodynamically stable. The neurological signs have shown significant improvement since this morning. Given the clinical signs, toxic ingestion was a primary differential, particularly marijuana toxicity, however, a urine drug screen was negative. Other potential toxins like macadamia nuts were also considered but access is reportedly nil. Ingestion of a sock is possible given the history, but he is not showing any clinical signs of a GI obstruction at this time. An alternative differential is mild intervertebral disc disease given the slight reaction over his mid-back, causing the wobbliness. A urinary tract infection is a less likely cause for the combination of signs but could contribute to the urinary incontinence. The clinical picture is most consistent with either a self-resolving toxicity from an unknown substance or mild spinal pain. He is stable for outpatient management with strict monitoring.Options offered to O:1. To admit to hospital for ongoing monitoring, IVFT, and further diagnostics including blood work and abdominal imaging.2. To manage as an outpatient with a trial of analgesia and close monitoring at home.3. Euthanasia was not discussed.O elected option 2TREATMENT:Paracetamol 500 mg PO q8Plan:Diagnostic Plan: as aboveTherapeutic Plan: as aboveDischarge Plan: Discharge with oral paracetamol. O advised to monitor closely. If he deteriorates, fails to improve, or shows other signs of illness, he should return for re-evaluation immediately. If he continues to improve, a check-up with the regular vet tomorrow is recommended to ensure the ataxia has fully resolved and he is comfortable.    Vital Signs