C09994202 / invoice 10000

Reason: V+ D+Appointment Notes: clHISTORY:Presented for one episode of formed vomit and two episodes of diarrhoea this morning. The owner is concerned about a flare-up of inflammatory bowel disease (IBD).The owner suspects dietary indiscretion two days prior, where Teddy consumed a piece of chicken or pork given by a stranger.Teddy has a history of IBD, managed at a specialist referral centre previously with hospitalisation. The owner is attempting early intervention for this episode.He also has a history of atopy, managed with Apoquel, an antihistamine, and a recent Cytopoint injection.His appetite and demeanour are reportedly normal.Current meds: Apoquel daily, half a tablet of an antihistamine daily.Vaccination: Not mentionedParasite Prevention: Simparica trioPre-existing conditions: Inflammatory Bowel Disease (IBD), Atopy.Diet: Royal Canin Hypoallergenic dry food. Prime 100 duck and sweet potato dry food is used as treats.Access to toxins eg. Rodenticide: noneEXAMINATION:Body Condition Score: 5/9Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): 1- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: exam not performedIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: not discussedPain Scale (0-4): 0/4Hydration status (%): hydration clinically adequatePROBLEM LIST:- Vomiting- Diarrhoea- Suspected IBD flare-up secondary to dietary indiscretionDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Gastroenteritis secondary to dietary indiscretion vs IBD flare-up.DIAGNOSTICS:NoneASSESSMENT:Teddy is clinically stable at this time. The clinical signs are most consistent with a mild gastroenteritis likely secondary to dietary indiscretion, or a mild flare-up of his known IBD. Given his history, prompt symptomatic treatment is warranted to prevent progression.TREATMENT:Cerenia injection administered S/C for anti-emetic and anti-inflammatory effects on the gut.Pro-Kolin paste dispensed to be given for 2-3 days to help bind the stool and re-establish normal gut flora.PLAN:Feed small, frequent meals of his normal diet for the next few days.Monitor for any further vomiting or diarrhoea.Continue Apoquel and antihistamine as normal for his itchiness.Re-evaluation scheduled for 09/03/2026 to discuss his ongoing atopy management.If there is any deterioration (further vomiting, lethargy, inappetence), he should be presented for re-assessment, which may include fluid therapy.Home into owner's care.CLIENT COMMUNICATION:Discussed the likely cause of the gastrointestinal upset is the dietary indiscretion. Explained the treatment plan, including the Cerenia injection which will last for 24 hours, and the use of Pro-Kolin paste. Advised to feed small, frequent meals and to monitor his faecal output, stopping the Pro-Kolin once stools have firmed up. Advised to return immediately if his condition worsens. The owner understands and consents to the plan. Discussed that we will revisit the management of his atopy at his appointment in four days.--- 06/03/2026 08:38:26 AM KTB:Examinations - Resolved - sms sent    Vital Signs    Weight: 3.65;       HeartRate: 120;       DentalGrade: 1;       RespirationRate: shake;       CRT: <2secs;       MMColour: pink;       BodyScore: 6;