C09975316 / invoice 10000

Not herself, froth mouth yesterday, bloody discharge around bum, constipated? diarrhoea? unsure as she couldn't see any poo in the yard but she was straining. Gave water oil and honey yesterday to try to help


History:
Reason: Lethargy, inappetence, bloody discharge around anus and tail
Diet: dog food
Preventatives: Due for flea, worming & tick treatment (new packet due to arrive soon)
Medications: nil
EDDU: abnormal - not eating dinner last night, drinking lots of water, straining to defecate
Coughing/Sneezing: no
Vomiting/Diarrhoea: yes - vomiting yesterday morning
Current Diagnoses: nil
Hx:
Owner reports dog had frothing and dribbling yesterday which settled. Last night dog was lethargic, didn't eat dinner, and was lying around instead of being the usual leader of the pack. Noticed bloody discharge around anus and up the tail. Dog has been straining to defecate. Owner gave small amount of plain water with vegetable oil last night which dog took a little of but still not right this morning. Dog chewed tennis ball down significantly the day before - owner removed it and put it away. Believe the dog may have eaten half of it. Dog was drinking lots of water last night. One episode of vomiting yesterday morning.

Examination:
DEMEANOUR: (Friendly)
MENTATION: (QAR)
GENERAL: BCS: (5)/9; HR: (110); RR: (pant); MM: p,m; CRT: <2; T: (38.2)
EARS: no discharge, swelling or erythema
EYES: no discharge or erythema
NOSE: no discharge
ORAL: no discharge or halitosis; ()/4 dental disease
CV: no murmurs or arrythmias
RESP: clear bronchovesicular sounds on all fields with normal effort
ABDO: comfortable; no palpable abnormalities
UROGEN: no discharge or swelling
MSK: normal gait
NEURO: no gross defecits noted
DERM: no external parasites; good coat; no lesions, pruritus or erythema
LYMPH: no peripheral enlargement
RECTAL: some blood, no faeces 


Problem list:
- Lethargy and inappetence
- Bloody anal discharge
- Vomiting
- Possible foreign body ingestion (tennis ball pieces)

Diagnostics:
CBC - monocytosis
Biochemistry - hyponatremia & hypoproteinemia likely from vomiting and inappetance. Hyperglycaemia due to stress. 
Radiographs - colon filled with gas. Gas also present in stomach

Assessment:


Client Communication:
Discussed need for radiographs and blood work to investigate possible foreign body obstruction from tennis ball ingestion. Explained that tennis ball material may not be visible on X-rays but gas patterns can indicate obstruction. May need multiple sets of X-rays taken hours apart to assess gas movement. Estimated cost of $600 for diagnostics. Client has pet insurance and will check coverage details with reception.

Treatments:
nil

Plan:
- Radiographs
- Blood work
- Assess for foreign body obstruction
- Monitor gas patterns on serial radiographs if needed

Discharge Instructions:
Patient admitted for diagnostic workup

Right front foot claw? + vacc
duramune, bronchi, proheart3

History

Reason: check right leg, also update vacc
Medications: nil
Preventatives: UTD
EDUD: normal
Coughing/Sneezing: nil
Vomiting/Diarrhoea: nil
Hx:
O says have been licking the RFL a lot in the last week. The dew claw is very long on that foot too. No other issues to report at home.

Examination

GEN: Weight: 21.3kg; BCS 5/9; BAR; HR: 180bpm; RR pant; MM: pink, moist; CRT: <2s; T: 39.0
EENT: no ocular, nasal, aural or oral discharge; teeth clean with no gingivitis; grade G0/T0
CV/RESP: no murmurs or arrhythmias on auscultation; clear bronchovesicular sounds on all lung fields
ABDO/URO: abdominal palpation soft, pliable, non-painful: no masses, organomegaly or fluid wave present; grossly normal external genitals
MS/NEURO: normal gait in room; no gross neurologic deficits noted; the RFL dew claw is hanging off
DERM: no external parasites noted; no lesions; good coat
LYMPH: no superficial lymph node enlargement
RECTAL: no t assessed; good anal tone on thermometer
BEHAVIOUR: no abnormal behaviour reported or observed during examination

Assessment

- Fit and healthy for vaccination
- Vaccinated with Duramune C3 SC
- Vaccinated with Protech Bronchishield IN
- Vaccinated with 1.2mL ProHeart SC
- Pulled dew claw off RFL - sprayed with betadine

Plan

- Vacc due in 1 year
- O can clean with betadine 1-2 times daily
- Rimadyl 100mg: give HALK tab SID with food for 4 days

VAcc- Proheart & bronchi shield3