Veterinary Emergency Inpatient Template

REASON: Vomiting and lethargy
HISTORY:
- The patient, a 5-year-old Labrador Retriever named Max, presented with sudden vomiting and lethargy over the last 24 hours.
- The owner notes that Max has been less active and has not eaten since the previous day.
- Pre-existing conditions: No known pre-existing conditions
- Access to toxins: No known exposure to toxins, bait, rubbish, medications, chemicals, or any other scavenged items.
- Current vaccination status: Up to date
- Current medications: None reported
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.