C10024198 / invoice 10000

HISTORY:Lola, a two-and-a-half-year-old dog, presented for a 24-hour history of vomiting and diarrhoea. The owner reports approximately 12 episodes of vomiting since yesterday morning. The vomitus is described as containing bile. There has been no visible blood in the vomit or stool. Lola is anorexic, having not eaten since the night before last, although food has been offered. She is still drinking some water. A degree of lethargy has been noted; while normally active, she has been quieter and more subdued, for example not barking at people walking past the house. The owner also noted she was licking at her paws last night. Lola has a history of chewing on inappropriate items. There has been no recent change in diet. She is typically fed kibble in the morning and a mix of chicken, rice, and supplements in the evening. She does not typically scavenge items on walks, but may do so in the backyard.Current meds: Nil.Prophylaxis: Not discussed.Pre-existing conditions: No significant prior medical history of this nature. Has had isolated episodes of vomiting in the past, but not to this extent.Triage:HR: 140RR: 20Temp: 38.2Mm: Gums are slightly dry and tacky.Crt: <2Mentation: Quiet, but alert and responsive.EXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): Mild discomfort noted on abdominal palpation.Hydration status (%): Assessed as mildly dehydrated based on tacky mucous membranes.Cardiovascular: cardiac ausculation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: Mentation appropriate. Plr positive , menace positive, palpebral positive . No abnormal strabismus or nystagmus positional or otherwise noted. Normal facial sensation and motor. Normal facial symmetry. Normal gag reflex. No neck pain. CPs and withdrawals present in all limbs. Patella reflexes intact. Cutaneous trunci reflex WNL. Strongly ambulating with no observable ataxia. Normal posture. Perineal reflex WNL. Adequate anal tone. Full exam not performedMusculoskeletal: Strongly ambulating x4. Adequate range of motion in joints, no overt swelling or painGastrointestinal:Oral: mild dental diseaseAbdominal: Abdomen is soft but appears mildly painful on palpation. Signs of nausea, such as lip licking, were observed during palpation. No organomegaly or fluid wave appreciatedRectal: not performedUrinary: no significant findingsReproductive (incl ext genitalia): no significant findingsIntegument/Ears: clean and shiny haircoat. No skin masses of lesions noted. No fleas or flea dirtLymph Nodes: peripheral lymph nodes palpable < 1cmEyes: no significant findingsPROBLEM LIST:Vomiting and diarrhoea (acute gastroenteritis)AnorexiaLethargyMild dehydrationMild abdominal discomfortDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Suspected viral or dietary-indiscretion-related gastroenteritis.DIAGNOSTICS:blood gas showed mild decrease in Na Cl and increase HCt indicating dehydrating ASSESSMENT:Lola presents with acute gastroenteritis, likely secondary to a viral infection or dietary indiscretion. She is showing signs of mild dehydration and nausea. The plan is to provide supportive care with intravenous fluids and anti-nausea medication to facilitate a quick recovery.TREATMENT:An intravenous catheter will be placed.hartmans 20ml/kg boluscernia 1mg/kg IV -zofran po tghprokolin PO tgh PLAN:Re-evaluate at approximately 7:30 am tonight.If clinically improved, Lola will be discharged for continued care at home.Medications to go home will be provided.Monitor for persistent vomiting or any worsening of clinical signs.CLIENT COMMUNICATION:Discussed with the owner that vomiting and diarrhoea are common in young dogs and are often self-limiting. The possibility of more serious causes was mentioned, but considered less likely at this stage given the presentation. The plan to hospitalise Lola for a few hours for IV fluids and medication was explained as the fastest way to help her feel better. The owner was informed that a mini blood test would be performed to check hydration and electrolyte levels. An estimate of costs around $700 was provided and approved by the owner. The owner was advised to return at 7:30 PM for discharge, assuming Lola responds well to treatment. They were reassured that the prognosis is good.    Vital Signs    

Reason: Y- Ate A nurofen This Morning - Been V+HISTORY: Lola started vomiting this morning. Owner found a chewed up tablet of neurofen on the bed, unsure how much is missing. Otherwise well pet prior. Not on any current medications. No known access to other toxins. EXAMINATION:Body Condition Score: 3/5Pain Scale (0-4): 0Hydration status (%): <5% dehydratedCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain- Abdominal: no detectable pain on abdominal palpation, normal gut sounds- Rectal: no detectable abnormalitiesUrinary: NSFReproductive (incl ext genitalia): NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFPROBLEM LIST:VomitingPossible ingestion of ibuprofenDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Ibuprofen toxicity - unknown dosageDIAGNOSTICS: nil ASSESSMENT: Lola presented for vomiting after ingesting an unknown amount of ibuprofen. A discussion was made on the potential adverse effects of NSAID toxicity and admission to hospital for treatment and baseline blood work was offered. Due to financial limitations, owner opted for home monitoring and conservative management. We recommend for her to be rechecked by her RVTREATMENT:Maropitant 1mg/kg SC @1800Omeprazole 5mg PO q12hrActivated charcoal POPLAN:Recheck with RV--- 6/02/2024 8:30:24 AM EMB:Examinations - Resolved -    Vital Signs