C10002674 / invoice 10000

Reason: Y - D+ 4 DaysISTORY:Presented for worsening diarrhoea over the last 4 days. The owner reports the onset of diarrhoea but no vomiting and no blood in the stool. He is still eating his normal food. He was given some chicken that was suspected to be off, and new new treats have also been ginen.Current medications: Not applicableProphylaxis: Not applicablePre-existing conditions: Not applicableAccess to toxins eg. Rodenticide: Not applicableTRIAGE:HR: 92 bpmRR: 24 breaths/minTemp: 38.3°CMm: pinkCrt: <2 secondsMentation: QAREXAMINATION:Body Condition Score: 3/5Pain Scale (0-4): 0Hydration status (%): euhydratedCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findings, no cranial nerve or proprioceptive deficits/gait detectedMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: no significant findings, no mouth pain- Abdominal: no detectable pain on abdominal palpation, normal gut sounds- Rectal: diarrhoea noted on rectal examinationUrinary: no significant findingsReproductive (incl ext genitalia): no significant findingsIntegument/Ears: no significant findingsLymph Nodes: no significant findingsEyes: no significant findingsPROBLEM LIST:- Acute diarrhoeaDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:- Dietary indiscretion- Food intolerance/allergy- Infectious gastroenteritisDIAGNOSTICS:Not applicableASSESSMENT:Presented for acute diarrhoea. On examination, he is bright, euhydrated, and afebrile. Abdominal palpation is non-painful. The likely cause is dietary indiscretion or a mild gastroenteritis, given the lack of other clinical signs. He is maintaining hydration and appetite.TREATMENT:Pro-Kolin+ paste administered orally, to be continued twice daily until diarrhoea resolves.PLAN:- Continue Pro-Kolin+ as directed.- Feed small, frequent meals of normal diet.- Monitor for changes in clinical signs.- Re-present if he stops eating, starts vomiting, becomes lethargic, or if blood is seen in the diarrhoea.CLIENT COMMUNICATION:Advised owner on the plan, including administration of probiotics and feeding management. Discussed the signs that would warrant a return visit, such as anorexia, vomiting, lethargy, or haematochezia. Owners understand the plan and when to seek further veterinary attention.    Vital Signs