OUTPATIENT VET

Reason for presentation: Patient presented with a three-day history of lethargy, inappetence, and vomiting. Pertinent History: - The patient, a 5-year-old female spayed domestic shorthair cat, has been progressively less active over the past three days. - The owner reports the cat has vomited several times, with the vomitus containing undigested food and bile. - The cat has shown a decreased interest in food and water. Additional History: - The cat is an indoor-only cat. - The cat is up-to-date on vaccinations. - The cat has no known prior medical history. Pre-existing conditions: No known pre-existing conditions Diet: Currently eating a commercial dry cat food. Access to toxins: No known access to any toxins, bait, rubbish, medications, chemicals nor anything else that could have been scavenged. Current vaccination/preventatives status: Up-to-date on FVRCP and rabies vaccinations. Receiving monthly flea and tick preventative (Revolution). Current medications: Nil mentioned Vitals: - BW: 4.5 kg - HR: 180 bpm - RR: 32 breaths/min - Temp: 39.5 Celsius - MM: Pink, moist - CRT: 1.5s - Mentation: BAR - Pain Score: 2/24 - Hydration status (%): 5% Physical Examination: Body Condition Score: 5/9 Pain Scale (0–24): 2/24 Cardiovascular: OMM pink, moist. CRT 1.5s. HS normal, no obvious HM or arrhythmias. Femoral pulses s/r, dorsal paedal pulses palpated. Respiratory: Eupnoeic. Normal BV LS all lung fields. No nasal discharge. Neurological: Mentation appropriate. No obvious neuro deficits. Full neuro exam not performed. Abdominal: Soft, comfortable and pliable. No obvious mass effects. Musculoskeletal: Ambulating normally, no apparent neck, spine, limb or joint pain, full musculoskeletal exam not performed. Oral: Unremarkable. Genitourinary: NSA. Normal external anatomy. Integumentary system: Skin turgor normal. NSA. Lymph Nodes: WNL on palpation. Eyes: NSA. Rectal: Not performed. Problem List: - Primary problem - DDx: Gastroenteritis, foreign body obstruction, pancreatitis, hepatic lipidosis. - P: Administer intravenous fluids, anti-emetics, and supportive care. Consider abdominal radiographs and bloodwork. - Secondary problem - DDx: Dehydration secondary to vomiting and decreased intake. - P: Continue intravenous fluid therapy and monitor hydration status. Diagnostics: - PCV/TP: PCV 42%, TP 7.0 g/dL - Catalyst chem17: ALT elevated, consistent with liver involvement. Assessment: The patient is a 5-year-old female spayed domestic shorthair cat presenting with a three-day history of vomiting, lethargy, and inappetence. Physical examination revealed mild dehydration. Initial diagnostics showed elevated liver enzymes. The patient is suspected to have gastroenteritis, with potential for other underlying causes. The patient was admitted for intravenous fluid therapy and supportive care. Client communications: The owner was informed of the cat's condition, the potential causes of the illness, and the treatment plan. The owner elected to proceed with diagnostics and hospitalization. The risks and complications of the treatment were discussed. Treatment: - Administered intravenous fluids (LRS) at a rate of 60 ml/hr. - Administered anti-emetic medication (Maropitant). Plan: - Discharge instructions: Continue to monitor the cat's appetite, water intake, and vomiting. Contact the clinic immediately if the cat's condition worsens. - Recommendations for monitoring and follow-up care, including medication list and future diagnostics or appointments: Recheck bloodwork in 24 hours. Continue anti-emetic medication as prescribed. Schedule a follow-up appointment in 3 days.