Comprehensive Veterinary Consultation Note

Clinician Specialty: Veterinarian History: The reason for the visit is lethargy, decreased appetite, and intermittent vomiting observed over the last 48 hours in a 7-year-old Labrador Retriever. The current condition began approximately two days ago with a gradual onset of subdued behaviour and reluctance to eat. Vomiting episodes started yesterday, occurring twice. No other additional concerns or secondary complaints were reported by the owner. Relevant previous medical history includes a spay at 6 months of age and routine annual vaccinations. The patient had a similar, milder episode of self-limiting gastroenteritis two years prior. Current medications include no regular prescription medications. The owner attempted to administer a small amount of boiled chicken and rice this morning, which was vomited. Physical Exam: Mentation: BAR Cardiovascular: HR 110 bpm; No murmur/arrhythmia, MMs pink and moist CRT <2, femoral pulses s+s Respiratory: RR 28 per minute; No adventitious lung sounds, normal effort/depth Eyes: Bright and clear OU Temperature: 39.2 C Ears And Nose: No naso-ocular discharge, ears NAD Teeth And Mouth: Mild dental tartar, pink mucous membranes. Abdomen: Mildly tense on cranial abdominal palpation, no overt pain elicited. Skin Turgor: NAD Peripheral Lymph Nodes: NAD Coat And Skin: Good condition, no ectoparasites seen Musculoskeletal: NAD, good RoM of limbs, no spinal or neck pain Neurological: Ambulatory, CNS NAD, gait NAD, spinal reflexes NAD, proprioception NAD Urogenital: NAD Body Condition Score: 6/9 Findings: Problem List: * Lethargy * Decreased appetite * Intermittent vomiting * Mild cranial abdominal tenseness Ddx: * Acute gastroenteritis * Pancreatitis * Foreign body obstruction * Early renal disease * Hepatic dysfunction Treatment And Plan: The findings of lethargy, vomiting, and abdominal tenseness were discussed with the owner, including the potential causes and the need for further investigation to rule out serious conditions. Treatment options offered included hospitalisation with IV fluids, antiemetics, and diagnostic blood tests (CBC, biochemistry, CPL) with an estimated cost of £400-£600, or outpatient management with subcutaneous fluids and oral medications if the owner preferred, with a follow-up visit tomorrow. The chosen treatment plan is hospitalisation for IV fluid therapy (Lactated Ringer's Solution at 5ml/kg/hr), antiemetic administration (Maropitant 1mg/kg SC SID), and diagnostic blood work (CBC, biochemistry, canine pancreatic lipase). The patient will be monitored closely, and the owner will be updated on blood test results and patient progress. Prognosis was discussed as guarded pending diagnostic results.