C10022550 / invoice 10000

Primary Presenting Complaint:Acute diarrheaOther Complaint:Selective appetite/inappetenceHistory:Diarrhea onset Monday, owner initiated probiotic therapy Monday night, condition deteriorated despite treatment. Patient has history of storm anxiety.    - Last Ate - Selective eating only, reduced appetite    - Vomiting - No vomiting reported    - Stool - Diarrhea since Monday, increased frequency overnight with minimal output ("few drips"), attempting to defecate frequently    - Diet - Currently on bland diet (boiled/steamed chicken), owner advised to continue bland diet with optional rice, sweet potato, pumpkin    - Microchip - Y/N - scanned - ok?Examination:Acute GI distress with significant borborygmi, otherwise stable    - Attitude - Anxious (possibly storm-related), otherwise responsive    - Body Score - Not documented, appears appropriate weight for 38kg dog    - Hydration status - Good hydration status    - Temperature - T 38.8    - Heart - Heart and lung sounds ok.    - RR - ok    - Dental - Score(0-4)= Mild calculus noted, grade not specified, overall dental health acceptable    - CRT - Good (normal)    - Eyes - WNL    - Ears - WNL    - Abd Palpation - Significant borborygmi noted, gut sounds audible and active, evidence of gut spasm    - Gastrointestinal - Marked borborygmi, increased gut motility, diarrhea with tenesmus    - Urogenital - No Sig Findings    - Skin - ok    - Musculoskeletal - No Sig Findings    - Neurological - No Sig Findings    - Lymphatic - No Sig Findings    - Other Key Findings - BW: 38kgAssessment:Acute gastroenteritis with suspected clostridial overgrowth causing diarrhea, gut spasm, and secondary nausea contributing to inappetenceProblem List:1. Acute diarrhea (onset Monday, worsening despite probiotics)2. Inappetence/selective eating3. Abdominal borborygmi with suspected gut spasm4. Mild dental calculusDDx:DDx for acute diarrhea with borborygmi and inappetence:- Clostridial overgrowth- Acute gastroenteritis (viral or bacterial)- Dietary indiscretion- Stress-induced colitis (storm anxiety as potential trigger)Discussed:Owner consented to treatment plan. Discussed cost difference between injectable convenia (~$230) versus oral metronidazole (~$40) - owner opted for oral antibiotics. Explained that metronidazole is preferred for suspected clostridial overgrowth. Advised that gut spasm may be causing nausea and contributing to inappetence even without vomiting. Owner instructed to continue bland diet, administer probiotics 1 hour after antibiotics, and can give paracetamol 2-3 times daily if needed for discomfort. Explained that condition should improve quickly with treatment. Owner comfortable administering oral medications.Treatment Plan:1. Buscopan injection 2ml s/c (anti-spasmodic) - administered in clinic2. Prevomax 3.8ml s/c anti-emetic injection - administered in clinic3. Metronidazole 400mg @ PO BID x 7 days (first dose to be given tomorrow morning, approximately based on 38kg BW)4. Continue prokolin probiotic therapy (administer 1 hour post-antibiotic)5. Bland diet (boiled/steamed chicken with optional rice, sweet potato, pumpkin)6. Paracetamol 500mg @ 1.5 tab PO BID-TID PRN for discomfortOngoing Prescriptions:Next Visit:Monitor at home, recheck PRN if condition does not improve or worsensThe above clinical notes were created with the assistance of Astro Scribe under the supervision of the consulting Vet.    Vital Signs    Weight: 38;