C10011769 / invoice 10000

HISTORYPresenting for:Riley presented for post-vaccination gastrointestinal upset following C5 vaccination and heartworm inj- was at MASH 2 days ago with vomiting and bloody diarrhoeaImproving but still has some blood in diarrhoea- brighter and no more vomitingHistorical Conditions:- Previous adverse reactions to heartworm vaccinations, with this episode being the most severe- Scheduled for dental treatment in 2 weeks for suspected fractured toothDiet:- No appetite for 2 days post-vaccination- Today eating wet food (sachets) at half normal amount, tolerating well- Previously fed kibbleV/D/C/S:- Vomiting began 9 hours post-vaccination- Diarrhoea started day after vaccination- Bloody diarrhoea developed the following day (day 2)- This morning continued mucous and blood in stool- Stool consistency improved today to half normal, half runny with some bloodOther:- Presented to emergency vet on Sunday due to concerns about bloody diarrhoea- Severe lethargy for 2 days, described as moving like a geriatric dog- Energy levels improved today, less lethargic- Drinking water observed todayEXAMBehavioural: Overall appears a better dog today, improved energy levels compared to previous 2 days when was flat outtpr normalrectal- blackish diarrhoeaAbdominal: Sensitive on palpationASSESSMENTPost-vaccination gastrointestinal reaction - Inflammation in gut with secondary ulceration causing bleeding, likely reaction to C5 vaccination/proheart. Patient showing clinical improvement.PLANVaccinations:- C5 vaccination reaction noted - patient alert added to give antihistamine prior to future vaccinations, will skip next years- Distemper, hepatitis, parvo component not due until 2028 (3 year duration)- Kennel cough component due in 1 year but will skip due to low risk lifestyle (stays home with house sitter)- Next vaccination scheduled for 2028 with pre-medication protocol- Consider oral heartworm prevention as alternative to injectionNew Meds/Tx:- Pro-Kolin dispensed to help firm stool and provide probiotics/prebiotics for diarrhoea recovery- Losec dispensed to reduce gastric acidity and assist healing of any upper GI ulcerationsAdditional Discussion:- Monitor faeces - if stool remains dark black colour may need reassessment- Dental treatment scheduled for 2 weeks may need postponement depending on full recovery- Patient showing improvement with better energy and appetite today    Vital Signs    Weight: 12.7;