Clinician Specialty: Veterinarian
SIGNALMENT: 7-year-old, female spayed, Miniature Poodle, 8.5 kg.
PRESENTING COMPLAINT: Owner reports "Penny" has been lethargic and anorexic for the past 3 days, with occasional vomiting.
GENERAL HISTORY:
- Penny's eating has decreased significantly, drinking appears normal. Urination and defecation are normal according to the owner. Vomiting has occurred 2-3 times a day, containing undigested food and bile. Owner denies any recent changes in environment or diet.
- Rimadyl (carprofen) 25mg PO BID for chronic arthritis, last dose 24 hours ago.
- Up-to-date on all vaccinations (DAPPv, Rabies) and receives monthly Heartgard Plus (ivermectin/pyrantel) and Bravecto (fluralaner) for flea and tick prevention.
- No known food allergies.
- Penny has lived with her current owner for 6 years since she was adopted. She lives with another cat, "Mittens," with whom she generally coexists peacefully. Her typical diet is Hill's Science Diet Adult Small Breed kibble.
- No significant stressors reported. Penny is generally calm and well-adjusted.
PHYSICAL EXAMINATION:
Habitus: QAR
HR: 120 bpm
Temp: 39.2 °C
Mucous Membranes: Pink, moist
CRT: <2 seconds
Pain Scale (0-4): 1 (mild abdominal tenderness on deep palpation)
Hydration status (%): 5-7%
Eyes: Clear, no discharge, pupils responsive to light.
Ears: Clean, no discharge or odour.
Nose: Moist, patent, no discharge.
Oral Cavity: Mild dental tartar, no gingivitis, no oral lesions.
Cardiovascular: Normal heart sounds, no murmurs detected, strong femoral pulses.
Respiratory: Eupneic, clear lung sounds bilaterally, no crackles or wheezes.
Abdomen: Mildly tense on cranial abdominal palpation, no overt pain or organomegaly noted. No foreign bodies palpable.
Integument: Coat is clean, no ectoparasites, no lesions or rashes.
Genitourinary: External genitalia appear normal, no discharge.
Rectal: Normal anal tone, no masses or abnormalities noted.
Musculoskeletal: Mild stiffness in hind limbs, consistent with known arthritis. Full range of motion otherwise.
Neurologic: Cranial nerves intact, normal gait, conscious proprioception normal.
Lymph Nodes: Peripheral lymph nodes non-enlarged.
Other: None.
DIAGNOSTICS:
Peripheral Blood Smear: No significant abnormalities noted.
Biochemistry: Elevated BUN (15.2 mmol/L, reference 2.5-9.6) and Creatinine (155 umol/L, reference 40-120), mild elevation in ALP (180 U/L, reference 20-130). Glucose, electrolytes, and other liver enzymes within normal limits.
Complete Blood Count: Mild leukocytosis (18.5 x 10^9/L, reference 6.0-17.0) with neutrophilia (15.0 x 10^9/L, reference 3.0-11.5). PCV 42% (reference 37-55%), normal total protein.
Radiography: Abdominal radiographs show diffuse gaseous distension of the small intestine. No clear foreign body or obstruction visible. Thoracic radiographs are unremarkable.
Ultrasonography: Abdominal ultrasound reveals mild thickening of the small intestinal walls and increased peristaltic activity. No mass lesions or free fluid detected. Kidneys appear mildly hyperechoic with good corticomedullary distinction.
Urinalysis: SG 1.025, pH 6.5, negative for protein, glucose, ketones, blood. SediView shows occasional squamous epithelial cells, no bacteria or crystals.
Ear Smears: Not performed.
Fine Needle Aspiration (FNA): Not performed.
Blood pressure: 130/80/95 mmHg
Spo2: 98%
ASSESSMENT: Penny presents with signs consistent with acute gastroenteritis and mild dehydration, potentially exacerbated by an acute kidney injury or chronic kidney disease given her age and biochemistry results. The abdominal discomfort and lethargy are likely secondary to the gastrointestinal upset. The elevated ALP is non-specific and could be related to stress or underlying liver involvement, or concurrent NSAID use.
TREATMENT AND PLAN:
- Discontinue Rimadyl temporarily.
- IV fluid therapy with Lactated Ringer's Solution at 50ml/kg/day for 24 hours to address dehydration and support renal function.
- Maropitant (Cerenia) 1mg/kg SC once daily for antiemetic support.
- Metronidazole 15mg/kg PO BID for 5 days to address potential bacterial overgrowth or dysbiosis.
- Prescription bland diet (e.g., Hills i/d) fed in small, frequent meals once vomiting subsides.
- Recheck biochemistry and CBC in 48 hours to monitor renal parameters and inflammation.
- Owner advised to monitor Penny closely for changes in appetite, vomiting, urination, and energy levels. If no improvement noted or deterioration in condition, owner to contact clinic immediately. Follow-up appointment scheduled for 3 November 2024.
SIGNALMENT: [Summarise patient signalment including age, sex, sterilization status, breed, spesie and weight] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PRESENTING COMPLAINT: [Summarise presenting complaints and reasons for visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
GENERAL HISTORY:
- [Describe the patient's relevant medical history such as their recent eating, drinking, urination, defecation, and vomiting habits, owner observations.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [State any current medications] (Include dosage and frequency) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Summarise patient's vaccination status, heartworm/flea prevention status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [State any food allergies] (Include their allergic response, if mentioned) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Describe the patient's relevant social history, such as whether they live with other animals, how long the owner has had them for, patient's typical diet] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Describe any stressors or triggers for the patient, such as other dogs, cats, loud noises, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PHYSICAL EXAMINATION:
Habitus: [Choose from either BAR, QAR, Dull, or Obtunded] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
HR: [Heart rate in bpm] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Temp: [Temperature in Celsius] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Mucous Membranes: [Mucous membrane assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
CRT: [Capillary refill time in seconds] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Pain Scale (0-4): [Pain assessment score] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Hydration status (%): [Clinical assessment of hydration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Eyes: [Detail eye examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Ears: [Detail ear examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Nose: [Describe nasal condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Oral Cavity: [Detail oral cavity findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Cardiovascular: [Detail cardiovascular system findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Respiratory: [Detail respiratory system findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Abdomen: [Detail abdominal examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Integument: [Describe integument condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Genitourinary: [Describe genitourinary system condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Rectal: [Detail rectal examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Musculoskeletal: [Describe musculoskeletal status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Neurologic: [Detail neurological examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Lymph Nodes: [Describe lymph node status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Other: [Detail any other physical examination findings that have not been mentioned above] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
DIAGNOSTICS:
Peripheral Blood Smear: [mention any peripheral blood smear findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Biochemistry: [mention any biochemistry blood test findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Complete Blood Count: [mention any CBC or Complete Blood Count findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Radiography: [mention any radiography findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Ultrasonography: [mention any ultrasonography findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Urinalysis: [mention any urinalysis findings including SG, Dipstick and SediView results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Ear Smears: [mention any ear smear findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Fine Needle Aspiration (FNA): [mention any FNA cytology findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Blood pressure: [Blood pressure in format systolic/diastolic/MAP] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Spo2: [pulse oximetry in %] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ASSESSMENT: [Summarise the assessment based on the above subjective and objective findings, include the vet's suspected diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Do not invent or infer a diagnosis.)
TREATMENT AND PLAN:
[Document the discussed detailed medical plan of action for both the patient and the owner to follow] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Always include a note that follow-up needed if no improvement noted or deterioration in condition noted.)
