C10011313 / invoice 10000

Appointment Notes: licking at front paw, red Was in the Southern Highlands over the weekendWhen returned noted that P was licking at the left fore leg, not limpingConstantly licking at left carpus areaDidnt finish antibiotic course - 2-3 daysProbiotic paste - prokolin for about 2-3 days after antibiotic courseVomiting and diarrhoea has resolvedHISTORYCLINICAL EXAMINATIONBar VinFocal spot of erythema/inflammation located over medial aspect of left carpus regionNo pain on flexion/extension of left carpus DDX/PROBLEM LISTAcute dermatitisTRT-Apoquel 3.6mg BID PO for up to 5d for anti-pruritic properties-Neocort cream BID on affected areas of skin for maximum 10 daysPlan:Offered ecollar - declined for nowCan pick up ecollar if required     Vital Signs    Weight: 6.7;       

Appointment Notes: V+ D+ since last Friday BIB MRSSubjective:History: Banjo, a 6-year-old male Toy Poodle, presented for vomiting and diarrhoea. The owner reports symptoms have been ongoing for approximately one week, worsening today.- Clinical signs/progression: For the past week, faeces have been soft with associated flatulence. Today, the patient had a large volume vomit of undigested food, followed by voluminous, mucoid, yellow-coloured diarrhoea. No blood was noted in the vomit or diarrhoea. The owner reports vomiting has occurred 1-2 times daily over the last week.- Significant history: History of recurrent, monthly episodes of gastroenteritis. Investigated for pancreatitis via X-ray 5 years ago. X-rays performed 4 years ago after lamb bone ingestion showed no obstruction. A lamb chop bone was given recently. Worming treatment is currently due. Vaccinations are up-to-date.- Current medications: None.- Appetite & diet: Inappetent and reduced water intake since this morning. Normally fed Royal Canin kibble and barbecue chicken. Currently being fed poached chicken.Objective:Vital Signs:- Blood Pressure: Not mentioned.- Heart Rate: 155- Respiratory Rate: 60- Temperature: 38.8°CDemeanour: Bright and alert.Examination Findings:- Eyes: Not mentioned.- Ears: Not mentioned.- Oral: Mild to mod PDD One tooth noted to have significant dental disease.- Nose: Not mentioned.- Peripheral lymph nodes: Not mentioned.- Cardiovascular: Not mentioned.- Respiratory, breathing: Not mentioned.- Urinary/Genital: Not mentioned.- Skin: No abnormalities.- Abdomen: Tense and tender on palpation.- Rectal examination: No abnormalities.- Neurological: Not mentioned.- Musculoskeletal: Not mentioned.- BCS: Not mentioned.- Hydration: Mildly dehydrated (dry mucous membranes).- Other Findings: Faecal smear performed, no parasites seen.Problem List:1. Vomiting and diarrhoea (acute gastroenteritis).2. Abdominal pain.3. Mild dehydration.4. Dental disease.- set reminderAssessment:Acute-on-chronic gastroenteritis. Clinical signs include vomiting, diarrhoea, abdominal tenderness, and mild dehydration. The faecal smear was unremarkable. Differentials include dietary indiscretion, infectious causes, or an exacerbation of a chronic condition such as inflammatory bowel disease or pancreatitis.Plan:Treatment Plan:- Maropitant 0.65 mL administered subcutaneously in-clinic.- Metronidazole 100 mg (1/2 of a 200 mg tablet) orally every 12 hours for 7 days.- Pro-Kolin paste 3 mL orally twice daily.- Lectade oral electrolyte solution to be offered frequently in small volumes.- Continue bland diet (poached chicken) in small, frequent meals.- Rest and avoid contact with other dogs.Progress Notes:- Initial presentation. To monitor response to treatment over the next 24 hours.Client Communications:- Discussed diagnosis of gastroenteritis and treatment plan.- Advised to contact the clinic if vomiting persists beyond 24 hours or if clinical signs worsen.- Discussed the potential need for further diagnostics (blood tests, faecal analysis, ultrasound) if signs are recurrent or do not resolve. Owner understood and consented to the plan.Allergies:- None known.Additional:- Prognosis: Good with symptomatic treatment.- Treatment Declinations: Owner declined a prescription digestive diet, preferring to use home-cooked chicken.?????    Vital Signs    Weight: 6.5;       

    Vital Signs