C10001899 / invoice 10000

HISTORY- Presents for worsening diarrhoea and lethargy.- Currently managed by primary care vet for a rodent ulcer on her lip, which has significantly improved with prednisolone 5 mg BID.- On Friday, developed vomiting and diarrhoea and was advised to decrease prednisolone to 2.5 mg; however, the owner did not administer the evening dose.- Has been passing ongoing diarrhoea and was inappetent this evening, with no further vomiting.- Blood work at the primary care vet this week showed an increase in neutrophils, mild dehydration, and no elevation in urea.- An elevated temperature was noted at the primary care vet, but the specific value is unknown.- Was administered a meropenem injection and discharged with a meropenem tablet for Sunday.- No changes to diet, which is a combination of Hills, Royal Canin, and Advanced foods.VITALS:HR: 180RR: 40Temp: 39.7MM: Pink & moistCRT: < 2 secondsMentation: QARPain Scale (MGCS): 3/10Dehydration status (%): MildBCS (1-9): 5/9Examination:Cardiovascular: NAD - normal rate and rhythm, no murmurs or arrhythmias auscultated, pulses strong and synchronous.Respiratory: NAD - no nasal discharge noted, normal respiratory rate and effort, bronchovesicular sounds are normal to all fieldsNeurological: NAD - normal gait, posture and mentation; full neurologic exam not performedGastrointestinal:- Oral: Oral mucosa appears normal, no lesions noted.- Abdominal: Normal on abdominal palpation, no obvious masses noted, comfortable and allows deep palpation Musculoskeletal: NAD - no evidence of lameness or pain. Full MSK exam not performed.Ears: NAD - pinnae normalEyes: Eyes clear with no obvious discharge or changes associatedLymph Nodes: NAD - peripheral LNs normal in size, no firm or painful LNs identifiedUrogenital: NADIntegument: NAD - coat normal, no obvious masses or other lesions; full exam not performedPROBLEM LIST:Pyrexia, diarrhoea, vomiting, hyporexia.ASSESSMENT:The cause of Cinnabun's vomiting and diarrhoea is unclear; however, it is suspected to be associated with steroid administration. There is concern for potential GI ulceration given the history of steroid administration and concurrent pyrexia, although there is no active concern on recent blood work.TREATMENT:Buprenorphine 0.2 mL transmucosally Q8-12h PRNOndansetron 2 mg transmucosally Q8-12h PRNPro-Kolin powder one sachet dailyOmeprazole 5 mg PO BIDPLAN:Monitor at home, encourage appetite, and return if any deterioration for admission and further investigation.CLIENT COMMUNICATION:Options were offered to the client: (1) outpatient medical management with instructions to return if any concerns, or (2) admission for further investigation and supportive care as an inpatient. The owner has elected for option one but understands that Cinnabun may need to return for option two if there is no improvement with outpatient care.    Vital Signs