C10029864 / invoice 10000

Reason: D+ V+. Appointment Notes: Overdue remindersReason: HISTORY:  Presented for acute onset of vomiting and diarrhoea today. The owner returned home from work to find multiple instances of vomit or diarrhoea throughout the house. At approximately 18:15, Neo passed a small volume of liquid green diarrhoea. Following this, he began shaking, cowering, and appeared uncomfortable. His demeanour was approximately 60% of normal after the episode. He has a history of coprophagia, which has caused vomiting in the past. There has been no change to his diet. He is a dog that tends to ingest inappropriate items, but the owner believes there was no opportunity for this today as he was secured in a dog-proof room. He has a brother who is well. His faeces were normal this morning. Current meds: noneVaccination: Not up to date. Became unwell after vaccinations in December 2025.Parasite Prevention: UTD.Pre-existing conditions: noneAccess to toxins eg. Rodenticide:Potential for ingesting bird droppings in the yard, but no known specific toxin exposure EXAMINATION:T 39.3 Pink MM, CRT <2 Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: 140,  cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory:thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological:neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4):not graded- Abdominal: no detectable pain on abdominal palpation, no obvious FF - Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: Anxious. PROBLEM LIST:- Acute vomiting and diarrhoea- Shaking and cowering post-defaecation- Lethargy (~60% of normal energy) DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:primary vs secondary GIT Primary: Inflammatory (gastroenteritis, AHDS) vs infectious vs toxin vs neoplasia vs other secondary: pancreatitis vs endocrine vs toxin vs other  DIAGNOSTICS:None ASSESSMENT:Neo presented for acute onset vomiting and diarrhoea. Clinical examination was largely unremarkable, apart from stress-related tachycardia. Given the clinical signs and history of coprophagia/dietary indiscretion, gastroenteritis is suspected. Other differentials were discussed. The owner has declined initial diagnostics (blood work) and an anti-nausea injection, opting for conservative management at this stage. He is currently eating and drinking. TREATMENT:  Discharged home.- Probiotics prescribed for 3-4 days to be administered orally.- Recommended a bland diet of boiled chicken and rice- owner declined maropitant  PLAN:Home into owner's care.The owner will monitor closely at home over the next 24-48 hours. Re-evaluation is recommended if clinical signs worsen, particularly if he stops eating/drinking, becomes more lethargic, or if vomiting becomes persistent. If diarrhoea does not show signs of improvement within 48 hours, re-assessment is advised. CLIENT COMMUNICATION:Discussed differential diagnoses for vomiting and diarrhoea, including gastroenteritis and AHDS. Two management options were offered: 1) Blood work to investigate underlying causes, or 2) Symptomatic outpatient treatment. The owner elected for symptomatic treatment with probiotics and a bland diet, declining blood work and an anti-nausea injection at this time. Advised that symptomatic treatment may mask underlying issues. Clear instructions provided on signs requiring immediate re-presentation: increased lethargy, inappetence, refusal to drink, and persistent vomiting. Advised that it may take 2-3 days for the diarrhoea to resolve. The owner was informed that if he re-presents within 24 hours, there will be no consultation fee. Owner understands the plan and when to seek further care.    Vital Signs