Outpatient (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 not eaten in the last 12 hours and has been less active than usual. - 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 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 clinical signs and examination findings suggest a possible case of gastroenteritis or pancreatitis. Dehydration is noted, and supportive care is required. TREATMENT: - Administered subcutaneous fluids (Lactated Ringer's Solution) 500ml - Prescribed antiemetic (Cerenia) 24mg once daily for 3 days - Advised bland diet for 3 days PLAN: - Discharge instructions: Monitor for any further vomiting or lethargy. Ensure Max is drinking water and eating the prescribed diet. - Recommendations for monitoring and follow-up care: Recheck in 48 hours if symptoms persist or worsen.