Reason
Buddy, a 5-year-old Golden Retriever, is presented today with a one-day history of vomiting and lethargy. The owner reports that Buddy has vomited three times, with the vomitus containing undigested food and a small amount of bile. He has also been less active than usual and has shown a decreased appetite. The owner is concerned about his overall condition and seeks veterinary care.
Pre consult
Nurse: Sarah Miller
Reason for visit: Vomiting and lethargy
Vaccine status: Up-to-date on all core vaccines, last administered 12 months ago.
Heartworm product/date given: Heartgard, given monthly, last dose 1st October 2024.
Worming product/date given: Drontal, given quarterly, last dose 1st October 2024.
Flea & Tick product/date given: Simparica Trio, given monthly, last dose 1st October 2024.
Diet: High-quality dry kibble, twice daily.
Insurance: Trupanion
Coastal Paws Member: Yes
Medications: None currently.
Do you consent to photos and videos being taken for social media? Yes
Pet Passport? No
History: Buddy has a history of mild seasonal allergies, treated with over-the-counter antihistamines. He is otherwise healthy, with no previous episodes of vomiting or lethargy. He is an indoor/outdoor dog, with regular walks and playtime. The owner reports no known exposure to toxins or foreign objects.
TRIAGE:
RR: 24 breaths/min
HR: 110 bpm
Temp: 102.5°F
"Mm: pink and moist"
Crt: <2 seconds
Mentation: BAR
EXAMINATION:
Buddy is bright, alert, and responsive. He is slightly dehydrated, with tacky mucous membranes. Abdominal palpation reveals mild discomfort, but no specific areas of pain or distension. The remainder of the physical exam is unremarkable. No fever detected.
Asseessment
Suspect acute gastroenteritis, possibly secondary to dietary indiscretion or mild viral infection. Rule out other causes of vomiting, such as foreign body ingestion or pancreatitis. Consider the possibility of mild dehydration due to vomiting.
Plan
* Administer intravenous fluids (Lactated Ringer's solution) to correct dehydration.
* Administer antiemetic medication (e.g., Maropitant) to control vomiting.
* Withhold food for 12 hours, then introduce a bland diet (boiled chicken and rice) in small, frequent meals.
* Monitor vital signs, hydration status, and response to treatment.
* If vomiting persists or worsens, perform further diagnostics, such as blood work and abdominal radiographs.
* Follow-up appointment in 2 days or sooner if condition deteriorates.
