C09977138 / invoice 10000

4 days diarrhoea in Consult Room 2
thursday vomited once, eating drinkin normal ( only new treats) up to date with vaccines

Subjective
Presenting Concerns:  
Alfie, a 2-year-old male entire blue Staffordshire Bull Terrier, presented for a 4-day history of diarrhea and vomiting.  
  
Historical Conditions:
-   Atopic dermatitis with an associated food allergy to beef and chicken protein and environment. tx apoquel daily
  
Diet/Appetite:
-   Currently on a single protein diet of duck and salmon biscuits.
-   Appetite is reported as good.
  
Drinking/Urination:
-   Drinking well.
  
V/D/C/S:
-   Vomited twice 4 days ago, soon after eating a chicken-based treat.
-   Has had soft, cowpat-consistency diarrhea for 4 days. The diarrhea has improved from liquid over the last day.
  
Additional Information:
-   The patient has otherwise been bright.

Objective
Mentation: BAR  
Wt: 37.5  
BCS: 5/9  
T: 38.1  
P: 80  
R: Panting  
MM: pink/moist. CRT < 2sec.  
Hydration: Normal  
  
Emotional Assessment:BAR  
  
Eyes: Clear. No discharge or erythema OU.  
Ears: Clean with no discharge or erythema AU.  
Nose: Clear, moist without discharge.  
Throat: No inducible cough upon tracheal palpation; no palpable masses.  
Oral: Calculus and gingivitis absent. No masses or other lesions.  
Cardiovascular: No murmurs or arrhythmias, strong synchronous pulses.  
Respiratory: Normal bronchovesicular sounds bilaterally.  
Abdominal: Soft and not painful to palpation.  
Lymph Nodes: No peripheral lymphadenopathy.  
Integumentary: No evidence of ectoparasites, full coat with clear skin.  
Neurologic: No ataxia, normal mentation.  
Musculoskeletal: Ambulation normal, no lameness observed.  
Urogenital: Normal external anatomy.  
Rectal: Not performed.

Assessment
Gastroenteritis - Likely a flare-up secondary to dietary indiscretion (ingestion of a chicken-based treat) in a patient with a known food allergy to chicken protein.

Plan
Medications/Treatments:
-   Pro-Kolin: 8 mL PO twice a day for 5 days.
-   Losec: 40 mg PO once a day, 20 minutes before food, for 5 days.
  
Diet & Feeding Recommendations:
-   Maintain the normal diet of duck and salmon biscuits.
-   No extra treats.
  
Additional Discussion:
-   Recheck in 5 days if there is no improvement in the diarrhea.