C10010739 / invoice 10000

HISTORY: REASON – D+ 3 days lethargic this morning and panting

HISTORY - O noticed diarrhoea for last 3 days, lethargy was only noticed this morning. O has another puppy to home and believes may have eaten some of the puppy food containing grain.

Hx of grain allergies.

Appetite: Normal 
Water intake: Normal 
Urination: Normal 
Faeces: dirrhea 
Energy levels: BAR
Coughing or sneezing: none
Vomiting: none
Diet: Grain free diet, reactive to grain, biscuits and wet food.
Parasite Control: not utd 
Vaccination status: utd
Current Medications: none

EXAMINATION
Demeanour: 
BCS: 5/9 
Integument: nad 
Eyes: nad
Ears: nad
Nose: nad
Mouth:-nad
CRT:          <2.5
MM: pink/slightly tacky
skin tent: <2
Dental disease: Grade - 0/4
HR:  120 BPM,    Rhythm: no arrhythmia or murmur 
RR:  pant BPM,    Effort: none
Temp:  39.3 C
Peripheral LN's: nad
Abdomen: minor stiff on cranial and caudal palpation, none painful. 
Musculoskeletal: nad
Neurological: nad
Urogenital: nad
Rectal: nad

ASSESSMENT:
-ddx: Acute gastritis vs pancreatitis vs FB obstruction vs metabolic vs neoplasm  
-dx: Acute gastritis 

CLIENT COMMUNICATION:
-Advise the owner (O) on the possible differential diagnoses (ddx) and the most likely diagnosis based on the history provided.
-Explain the plan going forward: Administer Prokolin (30ml, 3ml BID) for 5 days.
-Outline the next steps: If clinical signs persist or worsen, O should return to the vet for further investigation, including CP2, LP, CRP, and possibly an ultrasound (pending blood results).
-Diet recommendation: Feed bland chicken and rice for the next 7 days.

TREATMENT:
-Prokolin 30ml, 3ml BID for 5 days.

PLAN:
-Prokolin 30ml, 3ml BID for 5 days.
-If clinical signs persist or get worse, return to vet for further investigation (CP2, LP, CRP + possible ultrasound pending blood results). 
-bland chicken and rice for next 7 days.

ESTIMATES:
-$450 CP2, LP, CRP
-$850 ultrasound

REVISIT:
WEIGHT: 11.50