C10006602 / invoice 10000

REASON: Diarrhoea and vomiting, anorexia, and lethargyHISTORY:72-hour history of progressive gastrointestinal signs. Initially diarrhoea, owner not concerned as prone to GI upset, but this is worse than usual and has progressed. On the first day, there was also vomiting of bile with some mucus and a blood tinge.Yesterday, was seen by his regular veterinarian at Green Cross as he had also become inappetent, which is unusual for him. He was described as still bright and playful at this visit. Prescribed ondansteron, losec, and prokolin. Ate dinner last night, but vomited it all up around 3am. SInce last night, the diarrhoea became involuntary and is leaking out constantly. The diarrhoea is now described as watery, orange, and contains frank blood and mucus.He has had a recent weight loss from a normal weight of 10kg down to 9kg in the last three days.Pre-existing conditions: Has a known sensitive stomach and confirmed allergies to chicken and kangaroo protein. He is managed on a hypoallergenic diet of duck only.  Has had previous episodes of diarrhoea that were linked to dietary indiscretion and typically self-resolve.Access to toxins: No known access to any toxins, bait, rubbish, medications, chemicals nor anything else that could have been scavenged.Current vaccination status: utdCurrent medications: Was prescribed ondansetron and omeprazole by the regular vet yesterday. TRIAGE:HR:  132Mm: Tacky, slight injectedCrt: 2 secMentation: QAR, sleeping on consult room floorPain Scale (0-4): 1/4Hydration status (%): 5-7% dehydratedTemp: 38.3EXAMINATION:Body Condition Score: 5/9Cardiovascular: Cardiac auscultation revealed tachycardia but a normal rhythm. Pulse pressures normal and synchronous.Respiratory: Thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal discharge.Neurological: Appears dull but alert. Neurologically no significant findings, no cranial nerve or proprioceptive deficits/gait, full neurological exam not performed.Musculoskeletal: Ambulating normally, no apparent neck, spine, limb or joint pain, full musculoskeletal exam not performed.Gastrointestinal:Oral: NSFAbdominal: mild discomfort and no obvious abnormalities palpable, increased boborygmusRectal: not performed as very painful. Urinary: NSFReproductive (incl ext genitalia): NSFIntegumentary system:  painful perianal and scrotal dermatitis from faecal scaldingLymph Nodes: WNL on palpationEyes: NSFPROBLEM LIST:1. diarrhoea with blood and mucous2. Vomiting and nausea3. Dehydration, hypovolaemia, tachycardia and lethargy4. hyporexia and weight lossDIFFERENTIAL DIAGNOSIS:Dietary indiscretion/acute flare-up of food intolerance inflammatory bowel disease (IBD)Acute haemorrhagic diarrhoea syndrome (AHDS)Infectious gastroenteritisAddison's disease (hypoadrenocorticism)PancreatitisDIAGNOSTICS:> Baseline BloodsPCV:61TP:76Serum: clearBlood Gas Analysis Results - source:Findings: unremarkable.Bloods were taken for in-house testing:> Complete Blood Count  - Please find attached to the patient record.  - marginal neutrophilia, haemoconcentration> Biochemistry  - Please find attached to the patient record.  - marginal elevation ALT 127 (RR 10 - 125) otherwise unremarkable.ASSESSMENT:FOrrest presented for a three-day history of progressive vomiting and diarrhoea, which is now haemorrhagic and frequent. The primary concerns on presentation are his dull mentation, tachycardia, and signs of dehydration. The plan is to admit for hospitalisation for intravenous fluid therapy to correct dehydration and electrolyte imbalances, and to provide anti-nausea medication and analgesia. Baseline bloods will be performed to assess the degree of dehydration (PCV/TP), check electrolytes, and screen for other underlying organ dysfunction. Pending progress overnight owner aware may need to be transferred to primary care vet for ongoing care tomorrow. Owner is keen to pursue a specialist abdominal ultrasound to further investigate his chronic GI signs. --- 9/03/2026 2:33:21 AM KB:Been a very good boy in hospital, no further vomiting and has eaten his own food happily later this evening. Profuse diarrhoea persists however so ongoing fluid therapy and supportive care advised. --- 9/03/2026 9:47:53 AM MC9:Diarrhoea stopped for 5 hours, only smears. Spoke to O's advised as long as they are happy to manage diarrhoea, can go home as hit every other discharge criteria. When O came down and picked up Forrest, started leaking some diarrhoea again. Advised should still be okay but if not sure then can go to GP, O happy to take home. TREATMENT:-please see attached smartflowPLAN:The owners will bring in some of his duck-based food for when he is ready to eat.Recommendations for monitoring and follow-up care: The owners were advised that stabilisation is the priority. Further diagnostics such as specialist abdominal imaging (ultrasound), and specific testing for conditions like Addison's disease may be recommended in the morning depending on his response to initial treatment.    Vital Signs