Vet AI Scribe for Pocket Pets

Clementine

Monday, April 14, 2025 at 3:15 PM

Subjective

Chief Complaint

Owner reports five days of reduced pellet intake, dropping food from the mouth while chewing, and persistently wet fur under the chin.

History

• 3-year-old female guinea pig; housed with one cagemate, who is eating normally.
• Diet: timothy-based pellet, limited hay offered "a handful most days", and vitamin drops added to the water bottle.
• Faecal output visibly reduced over the past three days; pellets smaller.
• No recent diet or housing change; bedding is paper-based.
• Not previously seen for dental disease.

Objective

Vitals

• Weight: 780 g (down from 910 g four months ago)
• Temperature: 100.9°F
• Heart rate: approximately 240 bpm
• Respiratory rate: 60 breaths/min

Physical Exam

• General: Quiet, responsive; body condition 2/5
• Ptyalism: Chin, dewlap and both forelimbs damp with saliva; mild moist dermatitis of the chin
• Oral exam (otoscope, conscious): Elongated mandibular premolar crowns bridging over the tongue with partial lingual entrapment; sharp buccal spurs on the maxillary cheek teeth with a corresponding buccal mucosal ulcer on the right
• Incisors: Normal length and occlusion — dental disease here is entirely caudal
• Abdomen: Gut sounds reduced in all four quadrants; no palpable mass, no gas distension
• Musculoskeletal: Mild stiffness on stifle extension bilaterally
• Oral mucosa: Petechiae at the gingival margin

Assessment

Primary Problem List

1. Acquired dental disease with lingual entrapment by the mandibular cheek teeth
2. Hypovitaminosis C — petechiae, joint stiffness, poor healing, unreliable supplementation route
3. Reduced gastrointestinal motility secondary to anorexia
4. Weight loss (14%)
5. Moist dermatitis of the chin, secondary to ptyalism

Differentials

• Acquired dental disease — most consistent
• Oral foreign body or trauma
• Cheek tooth root abscess
• Primary gastrointestinal disease with secondary anorexia

---

Plan

Diagnostics

• Skull radiographs, four views, to assess reserve crown and root elongation
• CBC and biochemistry if the patient stabilises enough for volume-safe sampling
• Full oral examination under sedation with a rodent gag and cheek dilators

Treatment / Management

• Dental: Crown reduction of the elongated mandibular and maxillary cheek teeth with a dental burr under sedation. Nail clippers are not used — they fracture crowns below the gumline.
• Nutrition: Assist-feeding a critical care herbivore formula at 50 mL/kg/day divided into four to six feedings until voluntary intake returns
• Analgesia: Meloxicam 0.3 mg/kg PO q12h
• Motility: Encourage hay intake; no prokinetic while an obstruction is not excluded
• Vitamin C: 30 mg/kg PO q24h as a direct oral supplement. Water-bottle drops discontinued.
• Chin: Keep dry; barrier ointment as needed once ptyalism resolves

Follow-Up

• Weigh daily at home; report any day with no weight gain
• Recheck oral exam in 6-8 weeks; most guinea pigs with acquired dental disease need repeat crown reduction
• Reassess joint stiffness and gingival petechiae at 4 weeks on adequate vitamin C

Client Communication:
Explained that guinea pig cheek teeth grow continuously and that long-stem grass hay is the abrasive that keeps them worn — pellets do not provide the same chewing action, so a pellet-heavy diet gradually produces this problem. Also explained that vitamin C degrades within hours in a water bottle and that guinea pigs cannot synthesise their own, making direct oral supplementation the only dependable route. Hay should be available in unlimited quantity at all times rather than as a daily handful.

— Dr. Owen Brady, DVM