C09996700 / invoice 10000

lethargic, diarrhoea, biting at tummy like theres a pain?
owner asked for an u/s?

HISTORY:
Harry presented today for diarrhoea and vocalisation.
Diarrhoea noted first, initially watery, appeared to be improving then worsened. Small amount of mucus present, no blood. Vocalising/crying last night and today. No vomiting. Eating and drinking normally. Recently completed course of steroid tablets for skin condition. Other dogs in household did not develop similar signs.

Current medications: Steroid tablets (skin condition, recently completed course)
Diet: Raw mince or chicken (chicken sometimes cooked, sometimes raw), peas, occasional rice. Sensitivity to beef.
Parasite prevention: Trio Nexgard Spectra
Previous health concerns: MRI and surgery previously performed. Requires contralateral surgery.

EXAM:
- General Appearance: BAR, stressed
- Eyes: clear and bright
- Ears: clean
- Nose: no nasal discharge present
- Oral Cavity: teeth in fair condition, not concerning for today's presentation
- CV: no murmur or arrhythmias detected
- Resp: clear bronchovesicular sounds heard bilaterally
- Temp: 39.7¡C (upper limit 39.1¡C)
- Neuro: mentation appropriate, no overt cranial nerve deficits
- Integument: skin and hair coat clean and healthy
- Abdomen/GI: soft, not tense, not overtly painful, some findings on palpation, not dehydrated, no skin tent
- Musculoskeletal: ambulating comfortably in the consult room with no appreciable lameness or ataxia. Normal and comfortable ROM on gentle manipulation of all joints, no pain on palpation of spine or flexion of neck.
- Urogenital: not examined
- Lymph nodes: submandibular, prescapular and popliteal lymph nodes are of normal size and texture
- Rectal: no pain, normal faeces collected

ASSESSMENT:
- Pyrexia (39.7¡C)
- Diarrhoea with mucus
- Options discussed: supportive care vs blood work. Owner elected to proceed with bloods for peace of mind.

PLAN:
Treatment Plan:
- Blood work to be performed
- Harry to stay at clinic for 2 hours for bloods and results (30-45 minutes)
- Orthopaedic assessment of contralateral leg to be performed by David

Recommendations/Client Communication:
- Owner to be contacted once blood results available
- If further workup required based on bloods, owner will be called to discuss

Bloods WNL
Give prevomax SC 
low dose meth
prokolin

nails and skin

infalmmed axilla mild 
rest exam wnl - growly but didnt bite. 
wiggly for nails. 

vacc - recommend bethanthan for skin +/- steroids i gave other dog 

Presenting concern: proheart + nail trim 

History:
Eating, drinking, defecating, Urinating: all WNL 
Coughing sneezing, vomiting or diarrhoea: no 
Parasite control: (Proheart today, declined worming tick and flea)
O says Harry's other shoulder is playing up - has had surgery at specialist for one shoulder already 
No previous reactions.

Physical Exam:
Any limitations to the physical exam: none, animal was compliant with exam.
HR: (144)
RR: (panting)
T: (-)
BCS: (5/9)
Mm colour and CRT: pink, 2 seconds
Eyes ears nose mouth: clear, clean teeth
Heart and lungs: clear, no abnormal sounds 
Abdominal palpation: no abnormalities detected 
Lymph nodes: within normal limits 
Gait/ limb palpation: no abnormalities detected, no abnormalaties noted on flexion, extension of shoulder joints - tense, but overall anxious dog 
Skin: within normal limits 

Discussion:
Patient appears healthy on physical examination and would be suitable for vaccination today. 
Advised NSAID trail and if not improving then further diagnostics - o happy with this plan 

Procedure:
(Proheart)  administered subcutaneously. 
Clipped nails 

Plan: 
(Proheart)  next due in (12 months)
Meloxicam for 14 days, INI further diagnostics