C10032638 / invoice 10000

DATE/TIME of CONSULTATION: 04:48hrs, Fri 13/03/26
CLINICIAN: CX
PRESENTING COMPLAINT: vomiting and inappetence
HISTORY:
- Started vomiting 5AM yesterday, vomited several times, clear fluid. No vomiting yesterday afternoon and night, then started this morning again
- She was very lethargic yesterday, no appetite, not drinking. No diarrhoea, normal stool yesterday
- No known access to toxin. Not a known FB eater. No change in food. 
- She's on cephelaxin for a lump (suspected infection) on her paw, seems improving with antibiotics
- She has atopica daily for allergy and ongoing yeast infection in her ears and paws.
- UTD with vaccination and worming products. 

CLINICAL FINDINGS: 
Mentation: BAR  HR: 118  RR: 42  MM: pink and moist  CRT: <2s  Temp 38.4.
Clear eyes, nose and ears.
No skin tent
Heart auscultation nad, no audible murmur or arrhythmia
Normal respiratory effort. Clear BV sound
Abdominal palpation soft and comfortable. Normal gut sound
Peripheral LNs wnl
Rectal - empty 
The previous interdigital lump at RHL seems normal now, very mild erythema

PROBLEM LIST: vomiting, inappetence
DIFFERENTIALS: acute GE vs toxin vs FBO vs liver vs pancreatitis vs kidney vs endocrine vs others

DIAGNOSTIC TESTS:
Haemotology and biochem unremarkable
Tried to do abdominal ultrasound but too reactive without sedation. No FF. Stomach empty. No obvious intestinal dilation. 

TREATMENT:
- maropitant injection 1.9mL SC
- ondansetron 8mg BID if required
- Bland diet

CLIENT COMMUNICATION/PLAN:
- O need to monitor energy level, appetite, signs of vomiting/regurg/nausea very closely. If she's still vomiting or not eating with the medications, need to revisit at reg vet and do proper abdominal ultrasound/x-ray, may need sedation for this

DATE/TIME of CONSULTATION: 22:51hrs, Fri 13/06/25
CLINICIAN: Dr Peter Ballis

PRESENTING COMPLAINT: Gait NQR.

HISTORY:
Seemed fine today.
Taken for walk this afternoon/evening.
Nothing untoward happened on walk.
O noticed Luca seemed uncomfortable this evening.
Seemed to be having difficulty on both hind limbs.
At one point struggled to get onto her bed.
Has perked up since arriving at AVC.
No significant medical hx.
On atopica for skin issues.


CLINICAL FINDINGS:
B&A.
Mentation appropriate.
Somewhat hunched appearance.
No neuro deficits but lame on both hind limbs, R worse affected.
No knuckling or ataxia.
No neck pain.
Able to flex neck to the L and R and dorsi/ventroflex.
No evidence spinal pain.
Resents full hip extension both hind limbs.
Patellas stable.
No evidence stifle laxity.
No reaction on palpation/manipulation either stifle.
Lameness not exacerbated by exam.
mm=pink, CRT< 2sec.
Chest clear.
Normal resp rate and effort.
Heart NAD, rate=114 bpm.



PROBLEM LIST:
Bilateral hind limb lamaness.

DIFFERENTIALS:
? exacerbation DJD
? other

OPTIONS PROVIDED:
Suggested home with meloxicam next few days.
Reassess INI or worsening signs.