C09982723 / invoice 10000

Appointment Reason: 1.2 CONSULT 2, Appointment Notes: Had bouts of D++ since Monday afternoon, still her normal self. O wondered if she caught something at ARH over weekend - bhSubjectivePresenting Concerns:  Nova presented for a 2-day history of diarrhea, lethargy, inappetence, and adipsia.    Historical Conditions:-   The patient was recently seen at an emergency clinic and the Animal Referral Hospital for rapid breathing and a fast HR. An X-ray was performed, and she was given the all-clear on Monday. The diarrhea started after this visit.-   A previous blood test showed a slightly high T4, which was considered likely incidental in a young dog.-   A heartworm test was negative.  Diet/Appetite:-   The owner has been restricting food, offering only boiled chicken, which Nova ate last night.-   She was lethargic and had a reduced appetite yesterday.-   This morning, she has not eaten and is showing no interest in food.  Drinking/Urination:-   The owner reports that Nova is not drinking.  V/D/C/S:-   Diarrhea has been present for 2 nights. The consistency has progressed from soft-serve to watery and yellow-brown. One episode contained a small amount of blood. No vomiting has been observed.  Preventatives:-   The owner is unsure of the heartworm prevention status but believes a yearly injection may be due. Records are to be requested from All Pets clinic.  Lifestyle Risk Factors:-   Recently visited the Animal Referral Hospital.-   Visited a dog park where another dog was observed to have loose stools.ObjectiveMentation: BAR  T: 38.5°C  P: Normal  R: Normal  MM: pink/moist. CRT < 2sec.  Hydration: Normal    Emotional Assessment: The patient was friendly and accepted chicken treats during the examination.    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: Halitosis noted. Calculus and gingivitis absent. No masses or other lesions.  Cardiovascular: No murmurs or arrhythmias, strong synchronous pulses.  Respiratory: Normal bronchovesicular sounds bilaterally.  Abdominal: Mild pain on palpation of the cranial abdomen.  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: A digital rectal exam was performed. The colon was empty, and no fecal sample could be obtained.AssessmentAcute enteritis – DDx: Infectious (viral, bacterial, parasitic e.g., Giardia), dietary indiscretion, stress-related. The patient is currently stable, bright, afebrile, and appears clinically hydrated.PlanPending Diagnostics:-   A fecal collection kit was provided to the owner. If diarrhea persists, a fecal sample should be collected for a fecal float and Giardia test. The owner was instructed to refrigerate the sample if it cannot be brought to the clinic immediately.  Medications/Treatments:-   Pro-Kolin+: Dispensed. Give 5 mL PO BID. This is a probiotic with a stool firmer.-   Lectade oral rehydration solution: Dispensed. Mix both sachets into 2 L of water and store in the fridge. Offer 100-200 mL q 3 hours. Ensure fresh plain water is always available as well.  Diet & Feeding Recommendations:-   Continue offering a bland diet, such as boiled chicken. A commercial gastrointestinal diet (e.g., Hill's Gastrointestinal, Royal Canin Gastrointestinal) is also an option.  Additional Discussion:-   A recheck is recommended  (Monday), or sooner if her condition worsens.-   The reception team will contact All Pets clinic to obtain Nova's previous medical records to confirm her vaccination and preventative status.    Vital Signs    Weight: 16.6;