C10002695 / invoice 10000

Reason: Possible HGE - LmARRIVAL TIME:SIGNALMENT:History Summary:Presented for haematochezia. The owner reports Benson has been leaking frank blood from the rectum, which has progressed to passing frank blood and mucus upon attempting to defecate. The owner administered Pro-Kolin prior to presentation. A similar episode occurred approximately 3-4 months ago after dietary indiscretion (ingestion of a doggy birthday cake). Another episode of severe diarrhoea occurred approximately one year ago following a change in diet (raw). The current signs began yesterday morning after another diet change - given raw food and chicken foot. Not interested in food this AM. Retching and trying to vomit. Has been drinking more today. Preventatives: Reportedly up to date with parasite prevention but is due for vaccinations.TRIAGE:HR: 100RR: pant Temp: 38.3MM: pink, slightly tacky CRT: <2 Mentation: Bright and alert on presentation. Reported to be lethargic at home prior to arrival.Pain Scale: 1/4 Hydration status (%): Assessed as not significantly dehydrated, <5% EXAMINATION:Body Condition Score: 5/9Cardiovascular: 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, full neurological exam not performedMusculoskeletal: Able to rise and ambulate well with no obvious lameness, full MSK exam NP - Oral: NSF- Abdominal: NSF- Rectal: not performedUrinary: NSFReproductive (incl ext genitalia): NSFIntegumentary system: A firm lump right medial thigh area adjacent to femoral pulse- seems to be attached to muscle, approximately 2cm in diameter,Lymph Nodes: WNL on palpationEyes: NSFPROBLEM LIST:1. Haematochezia2. History of recurrent gastroenteritis secondary to dietary changes/indiscretion3. R muscular lump DIFFERENTIAL DIAGNOSIS:- Haemorrhagic gastroenteritis (HGE)/Acute Haemorrhagic Diarrhoea Syndrome (AHDS): likely secondary to dietary indiscretion.- Inflammatory bowel disease (IBD).- Infectious colitis.- Foreign body obstruction DIAGNOSTICS/MANAGEMENT PLANDiscussed with the owner that the degree of haematochezia indicates severe colonic inflammation, which carries a risk of bacterial translocation and dehydration/ hypovolaemia risks. Recommended hospitalisation for intravenous fluid therapy, injectable medications including analgesia and anti-nausea and monitoring, likely for a minimum of 12 hours. The owner's housemate, the primary caregiver, is en route to the hospital for further discussion and consent.PCV/TP: 52/ 63, clear EPOC: unremarkable REVISED ASSESSMENT:AHDS - secondary to dietary indiscretion, IBD has not been ruled out - O to consider specialist abdominal US in future PATIENT UPDATE:Stable/Improved: stable E/D/D/U/V: no V+ in hospital TREATMENT SUMMARY:Maropitant 1mg/kg IV Paracetamol 15mg/kg IV q8 IVFT - 1.5 x maint OWNER COMMUNICATION:CGR STO - actual O arrived, discussed PEx findings and recommended admission and baseline bloods, advised will help reduce risk for severe dehydration + hypovolemia, and will reduce duration of D+. Est 1500-1700 overnight, likely DC in AM. If declines, can perform full bloods and abdominal US. Discussed lump medial RHL - recommended to have FNA with PCV, could be previous muscle tear and healing that has now caused scar vs. benign or malignant mass. Text update: "Hi Brianna, it's Dr Claire at AEC, just a quick update for Benson, his baseline blood test that checked dehydration showed he was a little more dehydrated than first thought, it should be corrected by the fluids overnight. We are about to offer him some food, he has not been retching any more. He has not had any diarrhoea yet in hospital. I've just handed over to the overnight vet Dr Kelly, feel free to call for more of an update later, and we will call in the morning. Kind regards, AEC Kedron " FINANCIAL UPDATE: 1500-1700 PLAN:Hospitalise for intravenous fluid therapy, supportive care, and monitoring.############################################################Overnight update: KH Benson has not had any vomiting or diarrhoea overnight and has been eating well. Likely will be good to go home in the morning.    Vital Signs    Weight: 13.5;