Veterinarian's note

Patient Information: - Bella, Canine/Golden Retriever, 3 years old, Female Spayed - Mrs. Sarah Jenkins, 07700 900300, sarah.jenkins@email.com Subjective: - reason for visit: Bella presented today for a sudden onset of vomiting and lethargy over the past 24 hours. - presenting complaint history: Vomiting started yesterday morning, initially bile-stained, now appears to be food particles. Vomited approximately 5-6 times. Has not eaten since yesterday evening and has been unusually quiet and sleepy. No diarrhoea noted. No known exposure to toxins or new foods. Has been fed her regular commercial dry food. Owner attempted to give a bland diet (boiled chicken and rice) this morning, but Bella refused to eat it. No home treatments attempted. - past medical history: Up-to-date on all vaccinations (last boosters 6 months ago). No previous surgeries or chronic conditions. No known allergies. Currently on no medications. - dietary history: Fed Hills Science Diet Adult Large Breed dry food, twice daily. No recent changes to diet. - environmental history: Primarily an indoor dog, with supervised outdoor access in a fenced garden. No recent travel. No exposure to other animals outside of the household (one other dog, healthy). Active lifestyle with daily walks. Objective: - vitals: Temperature: 39.2°C (mildly elevated), Pulse: 100 bpm (within normal limits), Respiration Rate: 24 breaths/min (within normal limits), Body Condition Score: 5/9 (ideal), Weight: 28 kg. - physical examination findings: General appearance: Dull but responsive. Hydration status: Approximately 5% dehydrated (mild skin tenting). Integumentary system: Coat is clean, no lesions. Musculoskeletal system: No lameness or pain on palpation. Cardiovascular system: Strong, regular heart sounds, no murmurs. Respiratory system: Clear breath sounds, no increased effort. Gastrointestinal system: Abdomen is mildly tense on palpation in the cranial abdomen, eliciting a slight pain response. No foreign bodies palpated. Urogenital system: Appears normal. Nervous system: Mentation appropriate. Eyes: Clear, no discharge. Ears: Clean, no odour or discharge. Nose: Moist, no discharge. Throat: Oral mucous membranes pink, CRT < 2 seconds. - diagnostic tests: In-house blood work performed: CBC showed mild leukocytosis with a left shift. Serum chemistry revealed mild elevation in BUN and Creatinine (consistent with dehydration), and mild hypokalemia. Urinalysis via cystocentesis: Specific gravity 1.035, negative for protein, glucose, ketones, blood. Microscopic exam: few epithelial cells, no bacteria. Abdominal radiographs performed: Mild gas distension in the small intestines, no obvious foreign body or obstruction visible. Assessment & Plan: 1. Acute Gastroenteritis/Vomiting - assessment: Based on clinical signs, history, physical exam, and initial diagnostics, Bella is experiencing acute gastroenteritis, likely secondary to dietary indiscretion or an unknown pathogen. Mild dehydration and electrolyte imbalance are present. - differential diagnoses: Foreign body obstruction (less likely given radiographs), pancreatitis, renal disease, hepatic disease, infectious disease (viral/bacterial). - recommended diagnostics: Further diagnostics could include a SNAP CPL (canine pancreatic lipase) to rule out pancreatitis, or a faecal PCR panel if vomiting persists or diarrhoea develops. - treatment plan: - Maropitant (Cerenia) 1 mg/kg SC once daily for 3 days to control vomiting. - Metronidazole 15 mg/kg PO twice daily for 5 days for potential bacterial overgrowth/inflammation. - Subcutaneous fluids (Lactated Ringer's Solution) 300ml administered today for dehydration. - Bland diet (boiled chicken and white rice) to be introduced slowly in small, frequent meals once vomiting ceases for 3-5 days, then gradually transition back to regular diet. - Probiotic supplement (Fortiflora) once daily for 7 days. - procedures: None today other than diagnostics. - follow-up care: Recheck in 24-48 hours if vomiting persists or clinical condition worsens. Return sooner if Bella becomes severely lethargic, develops bloody vomit/diarrhoea, or shows signs of severe abdominal pain. Continue to monitor hydration and appetite. Additional Notes: - owner education: Owner was advised on monitoring Bella for continued vomiting, diarrhoea, appetite, and energy levels. Explained the importance of gradual reintroduction of food and strict adherence to medication schedule. Discussed the signs of worsening condition and when to seek urgent veterinary care. Emphasized preventing future dietary indiscretion. - emergency care instructions: Owner was given the contact number for the out-of-hours emergency clinic and advised to bring Bella in immediately if she collapses, has uncontrollable vomiting, severe pain, or bleeding from any orifice. - owner concerns addressed: Owner was particularly concerned about the possibility of a foreign body. Reassured her that radiographs did not show an obvious obstruction but noted that some foreign bodies can be radiolucent. Discussed the plan to monitor closely and potential for further imaging if symptoms persist.