C09990265 / invoice 10000

Reason: GI Issues Since Saturday W/ BloodAppointment Notes: pmReason: rescue dog. sat night gave dinner and took a while then eventually ate it. Didnt eat until monday then had a cup of biscuits tues didnt eat. Had chicken the last two days. Client Present: serena Nurse: ah Healthy Pets Wellness Testing: Done Yes / NoVaccination Type: utd Intestinal worming:Heartworm Prevention:Flea Prevention: nexgard spec due on the 2nd but hasnt taken as sick Tick control:Microchip: yInsurance and Healthy Pets Plus:Behaviour concerns: no Current medications: noCurrent Diet: prime 100 dry kibble Type of Shampoo/Frequency:Toileting: diarrheoa to start with then firmed up then diarrheoa started again yesterday morning __________________________________________________________________________Subjective:Diarrhoea and inappetence since 01/03/2026.Profuse diarrhoea on 01/03/2026. Refused food on 02/03/2026 with more diarrhoea. Ate one cup of biscuits on the morning of 03/03/2026 but refused food that night.A few drops of blood (haematochezia) observed on 02/03/2026, associated with straining.History of similar intermittent gastrointestinal upset.Possible triggers include swimming and ingesting saltwater, and eating three king prawns on 01/03/2026.Past medical history includes intermittent inflammatory gastroenteritis, acute kidney injury (resolved), anxiety, and elevated eosinophils on a previous blood test. Previous abdominal ultrasound was normal.Vaccinations are up to date. Previously treated for tapeworm.Current medications: none.Diet is normally Prime 100, with different flavours each week.Described by owner as a "highly strung" dog. No known access to toxins.Objective:Body Condition Score: Midlly overweight. BCS 6/9Pain Scale: 0/4.Hydration: Clinically adequate.Cardiovascular: Cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronous. HR 120 NMARespiratory: Thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal discharge.Gastrointestinal: No detectable pain on abdominal palpation. Oral examination normal.Neurological: No significant findings.Musculoskeletal: Ambulating normally, no palpable neck, spine, limb or joint pain.Demeanour: Bright and happy.Reproductive: Desexed female.Integument/Ears/Eyes/Lymph Nodes: No significant findings.Assessment & Plan: Acute on chronic gastroenteritis (colitis) with haematocheziaThe clinical presentation is most consistent with an acute flare-up of chronic inflammatory colitis, likely multifactorial (dysbiosis, potential dietary sensitivity/indiscretion, saltwater ingestion).Differential diagnoses include inflammatory bowel disease/food sensitivity, infectious gastroenteritis (viral, bacterial, parasitic), dietary indiscretion, and dysbiosis.Discussed diagnostic options if signs persist: faecal multiplex PCR, repeat blood tests including B12 levels, and repeat abdominal ultrasound.Probiotic supplement to be started If signs persist or worsen, recommend returning for further diagnostics, starting with a faecal sample for multiplex PCR analysis.If no improvement by 08/03/2026, owner to collect metronidazoleGabapentin and Trazodone (chill protocol) prescribed for anxietyAdditional Notes:Discussed the likely diagnosis of inflammatory colitis/dysbiosis. Discussed management of anxiety with a 'chill protocol' for stressful proceduresINI then faecal test/rpt bloods/consider US, may need diet trial down the line.    Vital Signs    Weight: 25.3;