C09997111 / invoice 10000

Reason: RevisitHistory: - presenting for recheck of rash/superficial dermatitis with male owner today - female owner reports diarrhoea started on saturday, sus after dietary indiscretion during walk in the park- owner reports initial diarrhoea had small amounts of bright red blood in it - resolving since, more solid consistency and no blood observed in stools since- owner also reports one off vomiting on the first day of diarrhoea - clear vomitus, no further vomits since - owners have been feeding chicken and rice the last few days to help settle stomach - eating well- is otherwise well within himself, no changes in energy or appetite levels- diet: hill's kibble normally, fed twice daily - was eating this well until the weekend, eating chicken and rice well- no c+/s+/v+ since initial episode, EDU ok - stools are of firmer consistency now- up to date with monthly parasite prevention and vaccinations- no other known health conditions, not on any medications/supplements- owner reports no other concerns todayExamination: GENERAL: BAR, very cute boy - reactive for rectal (growling), well-hydrated, mm pink and moist, CRT <2sHEART: HR 80 - bradycardic (owner says this is normal for him - has been brought up in previous visits), regular heart sounds, no obvious murmurs or arrhythmias, strong and synchronous peripheral pulsesRESP: sniffing and panting throughout, lung fields clear on auscultation - no crackles or wheezing, normal effort and no nasal dischargeEARS: external exam only - no discharge, no malodour, no obvious inflammation or irritationEYES: clear chambers, no discharge, symmetrical pupilsABDO: abdo soft and supple on palp, no palpable organomegaly, or massesLYMPH NODES: no peripheral lymph node enlargement on palpORAL EXAM: G0-1, minimal plaque build-up along gingival margin of upper canines, mild gingivitis observed MUSCULOSKELETAL: good general conformation and ambulatory on all four limbs, patellas bilaterally firm, no hind dew clawsINTEGUMENT: fur and coat in good condition, no ectoparasites on skinRECTAL: growling - no obvious palpable abnormalities, soft stools with no blood observed on glove Assessment: - sus acute gastroenteritis likely secondary to dietary indiscretion - resolvingTreatment: - 5mls pro-kolin PO BID until soft stools resolve Plan:- discussed likely cause is dietary indiscretion from scavenging on walks as owner suspected, recommended a muzzle to prevent eating inappropriate items- dispensed probiotic paste to be given twice daily to help firm stools, shown how to administer in consult - discussed weight management: aim for gradual weight loss to 11-12kg by reducing food quantities while maintaining twice-daily feeding schedule, owner to trial - advised on dental care: start brushing teeth to address plaque build-up on canines, quite minimal at this stage - advised owner to call if diarrhoea recurs, vomiting starts, or if there are any other concerns, owner happy with plan    Vital Signs    Weight: 13.3;