C09999323 / invoice 10000

Reason: Diarrhoea Past Few DaysHistory:Presenting for assessment of diarrhoea for the last 48hVery soft to liquid stools, fresh blood +, no mucusUrgency, mild straining after defecationNo vomitingA bit inappetent, but she is usually fussy with food anywayA bit quiet but not lethargicNo other symptomsIntroduced new treat last week - no other changes in diet or environment recentlyNo known access to toxinsNo known scavengerPrevious history - Suspected Addison's disease - adrenal glands below normal size on specialist's ultrasound + low resting cortisol - PLUS 3 nodules on spleen - owners decided to not pursue further investigations/treatment- Sensitive GIT - on gastrointestinal prescription dietNo other health concernsDrinking and urinating normallyUTD with vaccinations and preventativesDiet - gastrointestinal dry + wetExamination:T 38.2 HR 120 RR 28MM pink, CRT <2secsCOAT/SKIN: euhydrated, clean coat, no obvious skin lesionsEYES/EARS: clear, no obvious discharge or inflammationMOUTH: dental disease grade 2HEART: normal heart sounds, no obvious murmur or arrhythmiasLUNGS: normal BV sounds bilaterally, no obvious crackle or wheezing, normal respiratory effortABDOMEN/DIGESTIVE/URINARY: slightly tense on abdominal palpation, no obvious organomegaly or massesRectal exam - haemorrhagic diarrhoea, no other obvious alterationsCNS: BAR, anxious but friendly - ambulatory, no obvious neurological deficitsMSK: no obvious lameness, no obvious muscle atrophy, no full MSK exam performedPERIPHERAL LYMPH NODES: wnlAssessment:AHDS - dietary indiscretion vs inflammatory vs allergy/intolerance vs toxicity vs infectious vs metabolic vs endocrine vs GIT obstruction vs otherTreatment:Conservative treatment for nowPro-kolin 3mls PO BID for 3 daysContinue gastrointestinal diet, small & frequent mealsPlan:Recheck if not improving or deteriorating (profuse haemorrhagic diarrhoea, vomiting, anorexia, lethargy, etc) - consider bloodwork +/- imaging +/- faecal testingOwners aware GIT symptoms could be secondary to underlying suspected Addison's disease    Vital Signs