Patient Information:
- Winston, Canine, Labrador Retriever, 7 years, Male
- Jane Doe, 123 Oak Street, Anytown, AB1 2CD, 01234 567890
- 1 November 2024
Complaint:
- Lethargy, decreased appetite, and vomiting for the past 2 days.
- Winston started vomiting bile twice a day, and has been less interested in his food. He seems tired and less playful than usual. No known exposures to toxins. No home treatments attempted.
- Vaccinations up to date. No previous surgeries. No known allergies. On monthly flea and tick preventative.
- Currently eating a commercial dry dog food, twice daily. No recent diet changes.
- Primarily an indoor dog, with access to a fenced backyard. No recent travel.
Objective:
- Temperature: 103.5°F, Pulse: 120 bpm, Respiration: 28 breaths/min, Body Condition Score: 6/9, Weight: 75 lbs
- General appearance: Mildly dehydrated, lethargic. Integument: Normal skin and coat. Musculoskeletal: No lameness. Cardiovascular: Normal heart sounds, strong pulses. Respiratory: Clear lung sounds. Gastrointestinal: Mild abdominal tenderness on palpation. Urogenital: Normal. Nervous: Normal. Eyes: Normal. Ears: Normal. Nose: Normal. Throat: Normal.
- Blood work performed: CBC and chemistry panel. Abdominal radiographs taken.
Assessment & Plan:
1. Gastroenteritis
- Assessment: Likely gastroenteritis, possibly secondary to dietary indiscretion.
- Differential diagnoses: Foreign body ingestion, pancreatitis, infectious gastroenteritis.
- Recommended diagnostic tests: Continue to monitor blood work. Consider abdominal ultrasound if symptoms worsen.
- Treatment plan: Administer intravenous fluids, anti-emetic medication (Maropitant 1mg/kg SQ), and a bland diet (boiled chicken and rice) for 3 days. Monitor for improvement.
- Follow-up care: Return for reevaluation in 3 days if no improvement. Monitor for continued vomiting, lethargy, or bloody stool.
Additional Notes:
- Educated owner on the importance of a bland diet and monitoring for worsening symptoms. Provided instructions on medication administration. Advised to contact the clinic immediately if Winston's condition deteriorates or if he shows signs of severe abdominal pain or bloody vomit.
