Vet Medical Consult

Clinician Specialty: Veterinarian Vital Signs: - Temp: 38.5°C - Pulse: 120 bpm - Respiratory Rate: 30 bpm History: - Reason for current visit: Owner reports 3-day history of lethargy, decreased appetite, and intermittent vomiting in "Max," a 5-year-old male neutered Labrador Retriever. - Dietary history: Max typically eats Royal Canin Adult Large Breed dry food, 2 cups twice daily. No recent changes to diet, but has been picking at food for the past 3 days. No known dietary indiscretions. - Energy levels: Significantly reduced; usually very active but has been mostly sleeping. - Current or past medical issues: No significant past medical history. Up-to-date on vaccinations and deworming. Physical Exam Findings: - BCS: 5/9 (Ideal) - Mentation: Dull but responsive - Behaviour: Cooperative but subdued during examination. Eyes: - Clear, no discharge. Pupils equal and reactive to light. Conjunctivae pink. Ears: - Clean, no discharge or odour. No signs of inflammation. MM: - Pale pink, slightly tacky CRT: - 2 seconds Oral Cavity: - Mild tartar accumulation on canines and premolars. No obvious foreign bodies or lesions. Recommended dental cleaning in the next 6-12 months. - Teeth and gums appear healthy otherwise. Lymph Nodes: - Submandibular lymph nodes palpably normal. Other peripheral lymph nodes not enlarged. Cardiovascular: - Regular rhythm, no murmurs auscultated. Strong femoral pulses. Respiratory: - Clear lung sounds bilaterally, no crackles or wheezes. No increased respiratory effort. Abdomen: - Soft and non-painful on palpation. No obvious organomegaly or masses. Mildly distended with gas. Musculoskeletal: - No lameness or pain on palpation of limbs or spine. Normal gait observed. Integument: - Coat dull, but no ectoparasites, lesions, or alopecia noted. Skin turgor slightly reduced. Urogenital: - No external abnormalities noted. Testicles descended and normal. Neurological: - Cranial nerves appear intact. Proprioception normal. No ataxia or paresis. Rectal Exam: - Not performed. Diagnostic Results: - Complete Blood Count (CBC): Mild leukocytosis with neutrophilia. - Serum Chemistry: Mildly elevated BUN and Creatinine (pre-renal azotemia suspected), mild hypokalemia. - Abdominal Radiographs: Mild diffuse gas pattern in intestines; no foreign bodies or obvious obstructions. Assessment: - Problem list: 1. Anorexia/Hyporexia 2. Vomiting 3. Lethargy 4. Dehydration (mild) 5. Pre-renal azotemia Plan: - Medications prescribed or sent home: Maropitant (Cerenia) 16mg SC once daily for 3 days; Metronidazole 250mg PO BID for 5 days; Hills i/d canned food for 3 days. - Follow-up care or additional recommendations: Recheck in 48 hours for reassessment. Encourage small, frequent meals of bland diet. Ensure access to fresh water. Advised owner to monitor hydration status and vomiting frequency. Communications: - Discussed findings of dehydration, potential gastroenteritis, and mild kidney stress with owner. Explained treatment plan including medication administration, dietary changes, and follow-up. Owner approved diagnostics and treatment.