History, Examination, Diagnosis, Plan Note

History: A 7-year-old neutered male Domestic Shorthair cat, 'Whiskers', presented with a 3-day history of intermittent vomiting and lethargy. The owner reports that Whiskers has not eaten anything unusual, but his appetite has significantly decreased over the past 48 hours. He has also been observed to be less active and sleeping more than usual. Past medical history is unremarkable, with no known allergies. He is currently on no medications. Whiskers lives indoors, is up to date on vaccinations, and is the sole pet in the household. Family history is unknown as he was a rescue. Physical Examination: Upon presentation, Whiskers' vital signs were within normal limits: Temperature 38.5°C, Heart Rate 160 bpm, Respiratory Rate 28 bpm. General appearance noted mild lethargy but was otherwise bright, alert, and responsive. Mucous membranes were pink and moist with a capillary refill time of <2 seconds. Abdominal palpation revealed mild discomfort in the cranial abdomen, but no overt masses or foreign bodies were identified. Hydration status was estimated at approximately 5% dehydrated based on skin tenting. Oral examination revealed no abnormalities. Lymph nodes were non-palpable and peripheral pulses were strong and synchronous. Assessment and Diagnosis: Based on the clinical signs of vomiting, lethargy, decreased appetite, and cranial abdominal discomfort on palpation, the primary assessment is acute gastroenteritis. Differential diagnoses include foreign body obstruction, pancreatitis, inflammatory bowel disease, and renal insufficiency. Given the mild dehydration, supportive care is immediately indicated. Further diagnostics are required to rule out more serious underlying conditions. Plan: The immediate treatment plan includes subcutaneous fluid therapy (Lactated Ringer's Solution, 100ml administered once), administration of an antiemetic (maropitant 1mg/kg SC once), and a gastric protectant (famotidine 0.5mg/kg PO BID). Diagnostic recommendations include a complete blood count (CBC), serum biochemistry panel, urinalysis, and abdominal radiographs to assess for foreign bodies or other structural abnormalities. The owner was educated on monitoring Whiskers' appetite, water intake, and any further episodes of vomiting or diarrhoea. A bland diet (boiled chicken and rice) was recommended for 2-3 days, introduced gradually once vomiting has ceased. A recheck examination is scheduled for 1 November 2024 to review diagnostic results and assess clinical improvement. Referral to an internal medicine specialist will be considered if symptoms persist or worsen, or if diagnostic findings indicate a more complex condition.