C10024305 / invoice 10000

Reason: Shaking And PantingHistory:- Presented for lethargy and altered behaviour. Attempted to jump on the bed last night (12/03) and was unsuccessful.- At 3:00 AM, the patient went outside and upon return was observed to be shaking and would not lie down.- Behaviour has improved slightly at the time of consultation but remains wobbly and slower than usual.  Required lifting into the car where she normally would jump- Ate dinner last night and had some carrot at 10:30 PM. Was not food-oriented this morning. No unusual food intake reported.- Demeanour is not like her usual self.- Indoor/outdoor access. No recent travel history mentioned- No access to any known toxins or human medicationsPrior History:- Skin irritation a few months ago, treated with CCS and possibly antibiotics.- Vaccination status is uncertain; last vaccination was postponed due to medication for skin irritation. Worming and flea prevention status is uncertain.Current Medications:- No current medications.Examine: Temp: 39.5°C MM: Injected and moist CRT: <1.5s HR: 156bpm FP: N + S RR: PantingBCS: 7/9Weight: 19.8kgCardiovascular: No murmur auscultated, normal rhythmRespiratory: Normal BVS auscultated bilaterally, normal effort.  Mild URT stertorGIT: Abdomen is soft and non-painful on palpation. No vomiting or diarrhoea reported.U/G: NAD outwardlyNeuro: Mentation appropriate, pupils symmetrical and appropriately sized, CN all WIL, postural reactions normal.  No pain on neck manipulation or palpation.  No ataxia appreciatedM/S: No lameness appreciated, bilateral HL varusInteg: No prolongation of skin tent, no woundsOphth: NADLNs: All peripheral LN WILProblem List:Unsuccessful jumping attemptMild hyperthermia/pyrexiaWalking slowly, wobbliness at homeAssessment:Presents with vague signs including lethargy, reluctance to move, and a single instance of failing to jump. Mild pyrexia (39.5°C) may be attributable to stress/excitement in the clinic or a low-grade fever. Physical examination is unremarkable with no clear source of pain identified. A low-grade musculoskeletal strain or soft tissue injury is possible given the history.  Other considerations include low grade toxicosis (cannabis etc.)Treatment:Buprenorphine 0.3mg IMClient Communications:- Discussed that signs are non-specific and a clear diagnosis cannot be made at this time. Explained the rationale for symptomatic pain relief and the importance of close monitoring. The owner was reassured that Tina is currently stable.Options offered to client:1. Conservative management with close monitoring at home with a single pain relief injection to assess response.2. Further investigation with blood tests (haematology, biochemistry) as a screening tool to assess for underlying systemic disease, inflammation, or organ dysfunction.O elected option 1.Plan:Diagnostic plan: Monitor closely at home for the next 12-24 hours.Therapeutic plan: As aboveDischarge plan: Re-evaluation advised if no improvement within 8-12 hours, or if her condition deteriorates (e.g., persistent lethargy, inappetence, vomiting, diarrhoea, development of obvious lameness). Can return to the emergency department or visit their regular veterinarian.Referral plan: INI or worsening of signs, revisit with her RV    Vital Signs