Veterinary Consult Problem List SOAP

History: Whiskers, a 5-year-old female spayed domestic shorthair cat, presented for a 3-day history of lethargy, decreased appetite, and intermittent vomiting. The owner reported Whiskers had vomited bile twice yesterday and once this morning, with no signs of diarrhoea. The owner noted that Whiskers has been less playful and more withdrawn than usual, spending most of her time sleeping under the bed. Her appetite has significantly decreased, and she has only consumed small amounts of water. Additional concerns include a slight increase in vocalisation during the night, which is uncharacteristic for Whiskers. Previous medical history: • Feline calicivirus vaccination at 12 weeks old. • Spayed at 6 months old. • Annual health checks with no significant findings. Current medications: • None Travel/Import History: No recent travel or import history relevant to the patient. Physical Exam: • Mentation: Depressed but responsive. • Cardiovascular: HR 180 bpm; no murmur/arrhythmia, MMs pale pink and tacky, CRT 3 seconds, femoral pulses weak. • Respiratory: RR 32 per minute; no adventitious lung sounds, normal effort/depth. • Eyes: Bright and clear OU • Temperature: 37.8 C • Ears and Nose: No naso-ocular discharge, ears NAD - Teeth and Mouth: Moderate dental calculus, mild gingivitis. • Abdomen: Mildly tense on palpation, no overt pain noted, no organomegaly appreciated. • Skin Turgor: Reduced, indicative of mild dehydration. • Peripheral Lymph Nodes: NAD • Coat and Skin: Good condition, no ectoparasites seen, but coat appears duller than usual. • Musculoskeletal: NAD, good RoM of limbs, no spinal or neck pain • Neurological: Ambulatory, CNS NAD, gait NAD, spinal reflexes NAD, proprioception NAD • Urogenital: NAD • Body Condition Score: 5/9 Findings: Problem List: • Lethargy • Anorexia/Hyporexia • Vomiting • Dehydration • Pale mucous membranes • Weak femoral pulses • Moderate dental calculus/gingivitis Ddx: • Acute renal failure • Gastroenteritis • Pancreatitis • Foreign body obstruction • Hepatic lipidosis Treatment and Plan: The owner was informed of the physical examination findings, including signs of dehydration and potential abdominal discomfort. We discussed the severity of Whiskers' symptoms and the importance of prompt diagnostic investigation to determine the underlying cause. Treatment options presented included hospitalisation for intravenous fluid therapy, antiemetics, and diagnostic tests such as blood work (CBC, biochemistry, electrolytes), urinalysis, and abdominal ultrasound. Estimates for each option were provided and thoroughly reviewed. The owner elected for hospitalisation, intravenous fluid therapy, antiemetics, and full diagnostic work-up including blood tests and abdominal ultrasound. Whiskers was admitted for immediate care and monitoring. Preventative Care Recommendations: We discussed several recommendations for maintaining Whiskers' long-term health. • Dental Health: A professional dental cleaning was recommended to address the moderate dental calculus and gingivitis. The owner was advised on at-home dental care options, such as dental diets and tooth brushing, to prevent future build-up. • Vaccinations: We reviewed Whiskers' vaccination history and discussed the importance of booster vaccinations for feline calicivirus and panleukopenia, due next year. The owner was informed about common mild side effects like lethargy or soreness at the injection site, and advised to contact the clinic if any severe reactions like facial swelling or difficulty breathing occurred. She was also told to contact the clinic if lethargy or soreness persisted beyond 24-48 hours.