C09991322 / invoice 10000

Bloody diarhea
Last night and also this morning, dog ate only a bit of breakfast but it has been drinkin water, no lethargic, no vomiting.


Verified: NO

HISTORY
History compiled with help from transcription software, checked before completing

BIB: Male O
Current Complaint: Presenting for bloody diarrhoea

- Onset last night
- Anorexia this morning - did not eat breakfast
- Drinking normally
- Appears slightly dull and feeling sorry for herself but not significantly depressed
- Fine yesterday prior to onset
- Over last 2 nights has been anxious to get outside at night, hunting around fence area
- Suspected possible rodent ingestion - owner thinks may have caught something
- Owner initially thought vomiting last night but was actually diarrhoea

EDUF: Not eating this morning. Drinking normally. Passed bloody diarrhoea.
Diet: Kibble BID. Previously given steamed vegetables at end of week which caused excessive flatulence - this was discontinued.

Past History: Desexed - reportedly normal procedure. History of ear infection in past.
Travel: 
Other animals at Home: 1 other dog
Current Medications incl HW & fleas: In season 2 weeks ago
Presence of toxins - compost, plants, outside yard access: Access to yard with fence. Clamshell pool filled yesterday morning - patient drinks from this. Suspected possible rodent ingestion. Patient known to chew and hide items under tongue.

PATIENT DATA
Physical Examination:
Weight: kg
Temp: C
HR: bpm
Pulse quality: 
RR: 
MM colour: pink/moist
CRT: <1-2 sec
Respiratory effort: 
Lung sounds: 
Cardiac Ausc: NAD (partial auscultation completed)
Abdo palpation: Not completed - patient too stressed/aggressive
Gut sounds: 
Rectal/AG's: 
EENO: 
BCS 
Skin (including turgor): No evidence of dehydration on visual assessment
LNs: 
MSK: 
NEURO: BAR. NAD
Temperament/Demeanour Extremely fearful and stressed in clinic. Muzzle required for safety. Showed food aggression/defensive behaviour during examination. Previously reported as well-behaved at training classes.
Other P/E problems noted: 

Diagnostic Tests/Information: 

Treatments given:

ASSESSMENT
Problem List:
1. Acute haemorrhagic diarrhoea
2. Anorexia
3. Possible gastroenteritis

Dx: Acute gastroenteritis
DDx: Dietary indiscretion, infectious gastroenteritis, rodent ingestion, gastrointestinal inflammation
Plan:

In-Hospital Medication/s: 
In-Hospital Exercise: 
In-Hospital Nutrition: 

HOME CARE
Medications provided at discharge:
- Antibiotic PO (details to be confirmed)
- Stool binder with probiotics PO (details to be confirmed)
- Anti-nausea/GI protectant - oral dissolving tablet (details to be confirmed)

Home instructions:
Diet and/or exercise restrictions: Bland diet for 2-3 days then gradual reintroduction to normal kibble. Can add cooked pumpkin to bland diet to help firm stools.

CLIENT COMMUNICATION
Client Communication: Patient too stressed for complete physical examination. Sedation not recommended at this time as patient still eating treats and not dehydrated. Conservative treatment approach recommended with oral medications. If no improvement, next step would be sedation for full examination, blood collection, and radiographs. Monitor closely at home. Bland diet instructions provided.
Estimate: Conservative medical management selected.
Financial concerns: 
Discharge letter sent to referring vet? Email:

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SHIFT CHANGE: Day ---------- AM/PM: ---------- VET IN CHARGE:
Working Diagnosis:
In Hospital Vet Consult entered in Smartflow?
Time of last estimate update: O' informed of update:
Plan for this shift:
Discharge letter done ? -