C10018599 / invoice 10000

REASON: vomiting and diarrhoeaTime: 00:11AES Vet: Sara BaileyRegular clinic: North HobartHISTORY:- Presented for vomiting and diarrhoea. Reported as being very quiet at home.- Onset of vomiting at 5:00 AM, clear and watery. Second vomit at 8:00 AM. Soft stools noted this morning.- Watery vomit observed after owner returned from work. Diarrhoea also noted.- Owner became concerned after finding mucoid, bloody patches on the wee pads. Unsure if from vomit or diarrhoea.- Has vomited and defecated since being at the clinic; with patch of blood in the middle of the diarrhoea.- Has been observed retching without producing vomit.- Vaccinations: Completed puppy series. Not yet desexed, has had first heat cycle.- Diet: Recently switched to Lyca week ago. Previously on human-grade mince and steamed pumpkin. Has not eaten today but is typically a picky eater.- Environmental history: Indoor/outdoor access. Tends to eat pine bark in the backyard. Has access to children's toys and other items on the floor. Scoots occasionally.- Medications: On an anal gland supplement.EXAMINATION:HR: 100RR: 28Temp: NormalMM: Pink and moistCRT: <2 secondsMentation: Bright and alertPain Scale: Not assessedHydration status (%): Adequately hydratedWeight: 4.45 kgBody Condition Score: Not assessedCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal: - Oral: normal, no mouth pain, dental score: Not assessed - Abdominal: no detectable pain on abdominal palpation, normal gut sounds - Rectal: good rectal tone, no dilation. Diarrhoea present on examination.Urinary: bladder size smallReproductive (incl ext genitalia): intact female, vulva normal anatomyIntegument/Ears: clean furcoat no evidence of otitisLymph Nodes: peripheral lymph nodes normal size/shape & not painfulEyes: clear corneas, nil discharge or blepharospasmASSESSMENT AND PLAN:1. Acute Gastroenteritis- Likely diagnosis is acute gastroenteritis. Owner noted blood, but source (vomitus vs faeces) is unknown. Lethargy at home is a concern, suggesting significant discomfort, illness, or dehydration.- Differential diagnoses include infectious causes (viral), dietary indiscretion, foreign body obstruction, or acute haemorrhagic diarrhoea syndrome.- Diagnostic options discussed include abdominal radiographs to investigate for foreign body obstruction. Limitations of radiography (inability to see radiolucent objects) and the need for sedation were explained. The purpose of X-rays in this context is to rule in or out a surgical problem. Further diagnostics like ultrasound or repeat X-rays could be considered if there is no improvement.- Treatment options discussed: supportive care with anti-emetics and IV fluids in hospital vs. outpatient management with an anti-emetic injection and observation at home.- Owner elected to take Esme home.CLIENT COMMUNICATION:- Discussed assessment and differential diagnoses, including foreign body obstruction, infectious causes, and dietary indiscretion.- Explained diagnostic options, including the role, limitations, and costs of radiographs ($500-700). Explained the need for sedation for radiographs.- Discussed management options: hospitalisation for supportive care (IV fluids, medications) and monitoring versus outpatient treatment. Estimated cost for overnight hospitalisation with diagnostics is $1500-2000.- Discussed the option of transfer to North Hobart clinic in the morning for ongoing care and diagnostics if required, as they have more capacity for scheduled procedures.- Owner elected for outpatient management.- Provided home care instructions including withholding food overnight, introducing a bland diet (poached chicken and white rice) in small, frequent meals tomorrow, and monitoring for worsening signs. Dispensed Pro-Kolin to be started once eating.TREATMENT:- Maropitant  injection administered for vomiting.PLAN:- Administered Maropitant anti-emetic injection.- Dispensed Pro-Kolin paste.- Withhold food tonight to allow gut rest.- Commence a bland diet of boiled chicken and white rice tomorrow, offered in small, frequent amounts.- Start Pro-Kolin paste only once eating resumes.- Monitor for improvement (brighter mentation, reduced vomiting/diarrhoea) or deterioration (continued lethargy, persistent vomiting, worsening diarrhoea).- Advised to re-present to an emergency centre or their regular veterinarian tomorrow if not improving or if signs worsen..History Complete    Vital Signs    Weight: 4.45;