Inpatient (Veterinary Emergency)

REASON: Vomiting and lethargy HISTORY: - The patient, a 5-year-old Labrador Retriever named Max, presented with acute vomiting and lethargy for the past 24 hours. - Owner reports that Max has been less active and has not eaten since yesterday. - Pre-existing conditions: No known pre-existing conditions - Access to toxins: No known access to any toxins, bait, rubbish, medications, chemicals nor anything else that could have been scavenged. - Current vaccination status: Up to date - Current medications: Nil mentioned TRIAGE: - HR: 120 bpm - RR: 30 breaths/min - Temp: 39.0°C - Mm: Pink and moist - Crt: <2 seconds - Mentation: QAR - Pain Scale (0-4): 2 - Hydration status (%): 5% dehydrated - Blood pressure: 120/80/95 - Spo2: 98% EXAMINATION: Body Condition Score: 6/9 Pain Scale (0-4): Cardiovascular: Cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronous Respiratory: Thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal discharge Neurological: Neurologically no significant findings, no cranial nerve or proprioceptive deficits/gait, full neurological exam not performed Musculoskeletal: Ambulating normally, no apparent neck, spine, limb or joint pain, full musculoskeletal exam not performed Gastrointestinal: - Oral: NSF - Abdominal: Mild discomfort on palpation - Rectal: not performed Urinary: NSF Reproductive (incl ext genitalia): NSF Integumentary system: NSF Lymph Nodes: WNL on palpation Eyes: NSF PROBLEM LIST: 1. Vomiting 2. Lethargy 3. Dehydration DIFFERENTIAL DIAGNOSIS: Gastroenteritis, pancreatitis, foreign body ingestion DIAGNOSTICS: Nil performed ASSESSMENT: Max is a 5-year-old Labrador Retriever presenting with acute vomiting and lethargy. The primary concerns are dehydration and potential gastrointestinal upset. Differential diagnoses include gastroenteritis, pancreatitis, or foreign body ingestion. Further diagnostics are recommended to rule out these conditions. TREATMENT: - Administered subcutaneous fluids (Lactated Ringer's Solution) 500ml - Prescribed antiemetic (Cerenia) 24mg once daily PLAN: - Discharge instructions: Monitor for any further vomiting or lethargy. Ensure Max has access to fresh water at all times. - Recommendations for monitoring and follow-up care: Recheck in 48 hours if symptoms persist or worsen. Consider abdominal ultrasound if no improvement.