C09970328 / invoice 10000

Reason: D+ After Recent X-Rays AKSubjective:Diet: Boiled chicken and rice since FridayRecent changes to diet: Changed to bland diet (boiled chicken and rice) since Friday due to diarrhoeaPreventative healthcare:Vacc: HWP: IW: Flea/tick: HISTORY:O's presenting complaint/s: Diarrhoea for several days following anti-inflammatory medication- Patient presented for x-ray on monday last week- Started on Meloxicam before x-ray- Developed soft stool on Tuesday- Had diarrhoea Wednesday, owner stopped medication- Diarrhoea continued daily since Tuesday/Wednesday- This morning diarrhoea was watery consistency- Friday morning vomited grass and white material- Yesterday morning stool was slimy- No longer limping as was previouslyAppetite: NormalThirst: NormalVomiting: Vomited grass and white material Friday morning, nil sinceDiarrhoea: Watery diarrhoea daily since Tuesday, progressing from soft to slimy to wateryAccess to chemicals or toxins: Nil knownAccess to rodenticides: Nil knownCurrent medications: Probiotics (SamE), discontinued Meloxicam since FridayPrevious medical history: Recent x-ray for lameness, diabetes mentionedExamine:PHYSICAL EXAMINATION:Mentation: alert and responsiveEYES: NAD - clear, no noted dischargeEARS: NAD - clear, no discharge, odour, erythemaNOSE: NAD - clear, no discharge, symmetrical, no lesionsORAL: NAD - normal pink and moist mm, normal CRT, healthy teeth & gumsCARDIOVASCULAR - NAD - no murmur or arrhythmia auscultated, pulse pressures normal and synchronousRESPIRATORY: NAD - thoracic auscultation clear sounds bilaterally, respiratory effort normalABDOMINAL: NAD - soft pliable, no detectable pain or palpable abnormalitiesNEURO: NAD - neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMUSCULOSKELETAL: NAD - ambulating with normal gait & posture, no pain on palpation of joints, appropriate ROMRECTAL: not performedREPRODUCTIVE: externally normalINTEGUMENT: NAD - clear coat and skinLYMPH NODES: NAD - peripheral nodes palpate normalAssessment:Problem List:- Diarrhoea possible secondary to Meloxicam administration- could also be not related to meloxicam and previous visit- Rule out parasitic or bacterial infectionLameness under controlRecommend giardia test to rule out giadia. Also could be other infection. Requie faecal PCR to completely rule out. Laboratory:Giardia antigen test: negativeTreatment:Prokolin paste 5ml BID for 5 daysPlan:- Continue bland diet (boiled chicken and rice) for 3-4 days minimum- Can add pumpkin to diet- Gradual transition back to normal diet once improving- Return in 2 days if no improvement for faecal sample collection and further testing- Should see gradual improvement over next few days    Vital Signs