Inpatient Vet Note

Reason for presentation: Buddy, a 10-year-old male Labrador, presented with a three-day history of vomiting, lethargy, and inappetence. Pertinent History: - The owner reports Buddy started vomiting intermittently three days ago, initially after eating. - Vomiting has progressed to several times a day, with the vomitus containing undigested food and bile. - Buddy has become increasingly lethargic and has shown a decreased interest in food and water. - The owner denies any known toxin exposure or recent dietary changes. Additional History: - Buddy has a history of mild osteoarthritis, managed with a glucosamine and chondroitin supplement. - He is generally a well-cared-for dog, with regular veterinary check-ups and vaccinations. - No recent travel or boarding history. Pre-existing conditions: Mild osteoarthritis. Diet: Currently on a bland diet of boiled chicken and rice. 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: Buddy is up-to-date on his vaccinations and receives monthly heartworm and flea/tick preventatives. Current medications: - Glucosamine/Chondroitin supplement, 1 tablet PO daily. Neurological examination: - Mentation: Buddy is currently dull but responsive to stimuli. - Posture/gait: Normal posture and gait observed. - Postural reactions: Normal postural reactions in all limbs. - Spinal reflexes: Normal spinal reflexes. - Cranial nerves: Cranial nerves appear intact. - Spinal pain: No evidence of spinal pain. - Neuroanatomical localisation: No localisable neurological deficits. Problem List: - Vomiting - DDx: Gastritis, foreign body obstruction, pancreatitis, gastroenteritis, liver disease. - P: Administer antiemetics (maropitant), start IV fluids, withhold food and water for 12 hours, monitor for further vomiting. - Lethargy - DDx: Dehydration, pain, systemic illness. - P: Continue IV fluids, monitor hydration status, assess pain levels, perform diagnostics. - Inappetence - DDx: Nausea, pain, systemic illness. - P: Continue antiemetics, offer small amounts of bland food, monitor appetite. Diagnostics: - PCV/TP: PCV 40%, TP 6.5 g/dL, serum colour is normal. - Catalyst chem17: Mildly elevated ALT (120 U/L, RI: 10-100 U/L). - Vetnostics haematology and biochemistry: _pending_ - Point-of-care ultrasound: Mildly thickened intestinal walls. Instrumentation: - IV catheter placed in the left cephalic vein on 1 November 2024. Assessment: Buddy is currently stable but showing signs of dehydration and electrolyte imbalances secondary to vomiting. His mentation is dull, but he is responsive. Physical exam reveals mild abdominal discomfort upon palpation. The ALT is mildly elevated, suggesting possible liver involvement. Intestinal walls appear mildly thickened on ultrasound. Buddy has received IV fluids and antiemetics. Further diagnostics are pending. The patient's condition has not changed significantly since the morning review. Client Communications: Spoke with Mrs. Smith. Explained the diagnostic plan, including blood work and abdominal ultrasound. Discussed the possibility of a foreign body obstruction or pancreatitis. Informed her of the potential need for further diagnostics or hospitalisation. Mrs. Smith understands the plan and has authorised all necessary treatments. Explained potential risks and complications. Ongoing Assessment / Evening Update: Buddy's vomiting has decreased in frequency. He is still dull but more responsive. Continued IV fluids and antiemetics. No further client communications. Treatment: - IV fluids: Lactated Ringer's solution at 80 ml/hr. - Antiemetic: Maropitant 1 mg/kg IV q24h. - Analgesia: Buprenorphine 0.02 mg/kg IV q8h. Plan: - Discharge instructions: Continue bland diet, administer medications as prescribed, monitor for vomiting, lethargy, and appetite. Contact the clinic immediately if any concerns arise. - Monitoring and follow-up: Continue IV fluids overnight, repeat blood work and abdominal ultrasound in the morning, re-evaluate Buddy's condition, and schedule a follow-up appointment in 2 days.