C09998160 / invoice 10000

Consent to use Heidi: YesHistory:Presented for lethargy and trembling. Owner came home today to find Minnie lying at the front door, unwilling to get up. She was trembling in her right-sided limbs. Her right back leg felt tense on palpation.History of diarrhoea starting approximately two months ago, which was bloody at the time. This was treated with probiotics (Prokolin) for a few days and seemed to resolve. The owner reports she is not her normal happy self and is lethargic.The owner is concerned about giving too many treats.The bloody diarrhoea occurred for approximately three weeks, finishing about two weeks ago. The owner reports it was initially bright red liquid blood, which then became darker/black. The blood was passed with small amounts of faeces. This occurred once or twice daily.EDDU: OKVDCS: Reports a few sneezes over the last few days. No vomiting. History of diarrhoea which has now resolved.Diet: Mincemeat-style dog food in a packet from Coles or Woolies. Treats include Skinny Chicken Sticks, straps, and dental chews. Also receives some watermelon and banana.Current medications: noneMobility: Presented for an episode of being unwilling to rise and trembling today. Owner notes the right leg seemed painful.Current supplements: Was on probiotics but this was stopped.Behaviour: Lethargic. Normally is active and will chase a ball.Vaccination: UTD.Parasite Prevention: UTD.Pre-existing conditions: noneAccess to toxins: noneTriage:HR: 160 BPMRR: 34 BPMTemp: 39.0 CMM: PaleExamination:Demeanour: QuietBCS: 5/9CVS: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeEyes: NSFNose: NSFIntegument/ears: NSFOral: MM pale, CRT <2, healthy gingiva and teethLNs: WNLThyroid: No thyroid palpableAbdominal: no detectable pain on abdominal palpationMSK: ambulating normally, no palpable neck, spine, limb or joint abnormalitiesNeurological: NSFRectal: Not performedUrinary: NSFReproductive: NSFProblem List:LethargyTremblingUnwillingness to risePale mucous membranesHistory of haematochezia and melaenaWeight lossLaboratory:Bloods were taken for in-house testing:Please find attached to the patient record.> Complete Blood CountSignificant findings: Anaemia. No significant evidence of regeneration.> BiochemistrySignificant findings: Unremarkable.Assessment:Differential diagnoses for anaemia include blood loss (gastrointestinal) or haemolysis. Given the history of bloody diarrhoea, gastrointestinal blood loss is considered most likely. Potential causes include a gastrointestinal ulcer, foreign body, or neoplasia. The lack of regeneration may suggest iron deficiency secondary to chronic blood loss.The presenting signs of lethargy, collapse, and trembling are likely secondary to the anaemia. The examination revealed pale mucous membranes. In-house blood tests confirmed a non-regenerative anaemia. Other blood parameters were within normal limits.Treatment:Intravenous catheter placed for blood collection.Plan:An AFAST scan is recommended today to screen for major abdominal abnormalities or free fluid. This was scheduled for later this afternoon.Depending on the AFAST findings, a full diagnostic abdominal ultrasound with a specialist sonographer may be recommended to further investigate the cause of the gastrointestinal bleeding.Supportive medications for a potential stomach ulcer may be initiated.Close monitoring at home is advised.Client Communication:Discussed the clinical signs of lethargy and collapse. Explained that the pale mucous membranes were concerning for anaemia.Discussed the results of the in-house blood test, which confirmed anaemia. Explained the two main causes are blood loss or red blood cell breakdown, and that blood loss from the gastrointestinal tract is most likely given the history.Discussed differential diagnoses including ulcers (potentially medication-related, though none reported), foreign bodies, and cancerous growths.Discussed the diagnostic plan. An initial screening ultrasound (AFAST) was recommended today to look for any urgent issues. The cost of the consultation ($120), blood test ($245), and AFAST scan ($190) was discussed, with a total of $555. The owner consented to proceed.The option of a more comprehensive diagnostic ultrasound with a visiting specialist at a different facility was also discussed as a next step.Advised that if the AFAST scan reveals an urgent concern, referral for 24-hour monitoring over the weekend may be necessary. If not, supportive medications could be started.The owner was to take Minnie home and return later the same day for the AFAST scan.Discussed pet insurance and advised the owner to retain the receipt for a potential claim.    Vital Signs    Weight: 5.85;       HeartRate: 100;       DentalGrade: 1;       RespirationRate: 28;       CRT: <2;       MMColour: pale ;       Temperature: 39;       BodyScore: 5/9;       

Reason: Pls Call To Check In!! - recheck call from saturday History: Previous vomiting, diarrhea, wheezing, inappetenceGiven bronchodilator and antibiotics Further imaging with sedation if still unwell Examination: 24hrs after medication started feeling better. Owner has not noticed anymore D++ V++, inappetence has resolved with Minnie eating a lot more than she was when feeling unwell. Her energy levels have improved with her running and playing now also. Her breathing has improved with Minnie's owner reporting she is a lot less congested now. Minnies owner has no concerns and is happy to not go ahead with the imaging with sedation.--- 04/09/2025 10:31:13 SKL:Hx sent to records@petsure.com.auConsent from O via textApproved by SH    Vital Signs    

Reason: UnwellAppointment Notes: had been to reg vet for V+ and D+ and was given probiotics and was improving but today seems worse, pantingHistory: LethargicHad SR12 + bravecto + C5On rimadyl started with wheezing HISTORY:  Presented for investigation of vomiting, diarrhoea, wheezing, and inappetence. History of initial vomiting which resolved, followed by diarrhoea with blood. Attended McArthur Vet Group and was prescribed probiotics which initially helped. The diarrhoea has since recurred. Now presenting with wheezing, breathlessness, lethargy, and complete inappetence since yesterday. Went to MacArthur Vet Group for wheezing and started Rimadyl and had vaccinations done.  Current meds: Rimadyl, started recently.Vaccination: UTD. C5Parasite Prevention: UTD. heartworm injection,  bravecto quantum, allwormer.EXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory:Wheezing in consult when neck extended, thoracic auscultation normal  Neurological:neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): 2, mild calculus - Abdominal: no detectable pain on abdominal palpation, tense on palpation but not reactive, no palpable foreign bodies, fluid or masses - Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: Lethargic. PROBLEM LIST:- Vomiting - Diarrhoea with blood- Respiratory signs (wheezing, breathlessness)- Inappetence- Lethargy DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS: DIAGNOSTICS:Bloods were taken for in-house testing:- Please find attached to the patient record.> Complete Blood Count- Significant findings: White cell count normal. Platelets clumped, but adequate on smear. > Biochemistry- Significant findings: Electrolytes, kidney, liver, and pancreatic values are within normal limits. Mild decrease in phosphate. Radiology: Digital radiography was performed.Thoracic:  Extra thoracic structures:no significant abnormalities, skeletal and subcutaneous structures normalDiaphragm: IntactPleural space: No air or fluidLarge airways: Normal, normal dorsal tracheal membranePulmonary: No pathological pulmonary pattern presentCardiac:Normal size and outlineOesophageal:no air or foreign body present ASSESSMENT:Minnie presented for lethargy, inappetence, recurrent diarrhoea, and new-onset respiratory signs (wheezing/gasping). Bloodwork was largely unremarkable, ruling out significant systemic infection or organ dysfunction. Thoracic radiographs of the throat region did not reveal any obvious foreign body or other significant abnormality. The cause of the clinical signs remains undetermined, though an infectious or inflammatory process is suspected. TREATMENT:  Discharged home.- Trial course of a bronchodilator.- Trial course of antibiotics.PLAN:Trial medication at home. Monitor for improvement in appetite, energy, and respiratory signs.If no improvement, further imaging with sedation may be required.Home into owner's care. CLIENT COMMUNICATION:Discussed the results of the blood test and X-ray, which did not provide a definitive diagnosis. The cost of the in-house blood test was confirmed at $200. The plan to trial a course of medication (bronchodilator and antibiotic) was discussed. Advised that if Minnie does not improve, more complete X-rays under sedation would be the next step. Owner understands and consents to the current plan.    Vital Signs    Weight: 6.65;       HeartRate: 120;       DentalGrade: 1/4;       Temperature: 38.1;       BodyScore: 5/9;