C10032462 / invoice 10000

14/03/2026 Reason: VOMITING

History:

Owner reports vomiting began last night around 23:45 with vomit on daughter’s bed; another vomit found later on owners’ bed.
Overnight vomit described first as undigested dry food, later as brown digested material.
This morning had two episodes of vomiting after drinking water; unable to retain water.
Owner noted shivering this morning which has resolved.
Owner perceives he felt warm at home.
Owner reports increased clinginess and being unusually quiet this morning; stayed by owner’s side.

Possible urinary accident noted overnight with urine in hallway; colour described as normal yellow.
No known dietary indiscretion; food is dry kibble available for grazing.
No diarrhoea observed at home prior to visit.
No typical history of gastrointestinal problems; occasional isolated vomit only.

Owner notes chewing at a hind digit sometimes after nail trims and noticed 2 new lesions on the foot in the last day.
Owner reports high anxiety with other dogs and on leash.

Vaccinations were due in January and were missed due to travel.
Owner states intestinal worming is performed at home.
Prior dental procedures; concern about dentition. Owner recalls prior anaesthesia event where heart was noted as "funny" but thought to be very fit.


Any other concerns: Chronic oral health issues
On any medication: None
Changes in behaviour: More clingy and quiet this morning; perked up upon arrival at clinic.
Changes in eating/drinking: Grazes dry food normally; last night had typical access to dry food. This morning unable to keep water down.
Changes in activity levels: Owner reports he was racing around and playing about 2 hours before first vomiting episode; this morning was lethargic and stayed by owner.
Changes in toileting: Possible urinary accident in hallway overnight; no diarrhoea seen.

Routine Health Care:
Microchip Checked - Y
Vaccinations Up to Date - N - due once he is well
Vaccinations Next Due - 
Intestinal Worming Up to Date - Y @ home
Intestinal Worming Product -
Heartworm Prevention Up to Date - N - SR12 is due
Heartworm Prevention Product -
Flea Prevention Up to Date - 
Flea Prevention Product - 
Diet History - Optimum dry food adlib
Pet Insurance - Y

Physical Examination:
Temperature: 38.8
Pulse: 108.0
Respiratory Rate: WNL
Blood Pressure: [Not Mentioned]
Body Condition Score /9: 5/9
Dental Grade: Severe periodontal disease with gingival recession affecting 104; multiple large molars previously missing/extracted.
Thoracic auscultation: Heart auscultation with HR 108 bpm, regular rhythm. Lungs not specifically described.
Abdominal palpation: Guarding noted on palpation of cranial abdomen
Eyes: NSF, corneas appear clear and free of discharge, pupils normal size, globes symmetrical OU
Ears: NSF
Oral Cavity: Marked periodontal disease with heavy calculus and gingival recession of a canine tooth; concern for tooth viability. Missing large molars.
H/Lymph: NSF
Skin: Crusts noted left mid chest wall; 2 lesions observed on the foo (left hind digit 2) per owner with chewing at the digit.
Musculoskeletal: NSF
Urogenital: NSF
Neurological: NSF
Pain Score (/10): 2/10

Routine Investigations:
Haematology: Recommended and approved; results pending.
Biochemistry: Recommended and approved with pancreatic assessment; results pending.

Assessment:
Differentials: Acute gastroenteritis vs pancreatitis vs dietary indiscretion considered due to acute vomiting and abdominal guarding. 
Less likely toxin/foreign material ingestion per owner history, but not excluded.


Plan:
Admitted for the day for IV fluids, injectable antiemetic, and bloodwork including pancreatitis testing. 
Monitor hydration status, vomiting frequency, and anxiety in hospital. 
Avoid oral medications initially due to vomiting. 
Target discharge approximately 16:30 today. 
Vaccinations deferred until recovered. Discuss dental procedure planning once gastrointestinal issue resolves.







14/03/2026 INPATIENT CARE

Reason: Vomiting, Hepatitis          Day: 1
Case Vet: JT
Treatment Vet: Ru
Nurse: SN

Physical Examination: 
HR: 
RR: 
CRT: 
MM: 
Temp: 

Fluid Therapy: 
Fluid type:  Hartmann's 
Fluid rate: 60ml/hr
VTBI: 
VI: 

Subjective:
Eating (Feeding plan):
Drinking:
Urinating:
Defecating:
Pain score:

Assessment:

Treatment:

Plan: Recheck on Monday morning. If liver enzymes have cont to increase, will nee abdo ultrasound to investigate further.

Owner updated: Yes at 12.45pm. Discharge time confirmed.
Cost updated: N

14/03/2026 PATHOLOGY RESULTS: QLD
Phone call with Simone @ 11.40am
 - advised that the blood results show acute hepatitis (the ALT is too high for the Catalyst to read) 
 - elevated ALT,ALP, GGT & Bilirubin
 - elevated CRP
 - WCC normal
 - discussed that we know that the liver is unhappy but we don't know the cause
 - advised that the liver is difficult to investigate and that our options over the weekend are lmited
 - given that Fergus is still surprisingly well we are going to treat symptomatically over the weekend and recheck Monday to repeat bloods and consider abdo ultraound.
 - if he deteriorates over the weekend he will be taken to SASH