Spencer
Thursday, March 21, 2024 at 2:57 PM
Subjective
Chief Complaint
Spencer, a small dog, presented for a follow-up appointment due to persistent diarrhea and frequent episodes of gastrointestinal distress.
History
- Persistent diarrhea for three weeks, with episodes of bloody, jelly-like stool.
- Vomiting episodes, described as white foam or yellow bile.
- Decreased appetite over the past three weeks, with associated pacing and discomfort.
- History of Clostridium infection treated with metronidazole a year ago, with intermittent minor episodes since.
- Recent weight loss from 12 pounds to 9.6 pounds.
- Occasional loud stomach rumbling associated with pacing and discomfort.
- Recent dental cleaning with noted concern for low albumin levels.
- Current medications include probiotics, folic acid (200 mg once daily), and famotidine.
Objective
Vital Signs
- Temperature: WNL
- Weight: 9.6 pounds
- Heart Rate: WNL
- Respiratory Rate: WNL
- Capillary Refill Time: WNL
- Body Condition Score: Reasonable weight, graded as 4-5 on a 9 scale
Physical Exam
- Eyes: - Normal. Retinal exam normal
- Ears: Clean with no discharge or erythema AU.
- Oral: Teeth clean, no gingivitis or tartar.
- Cardiovascular: Normal heart rate, sinus rhythm, no murmurs. Strong and synchronous pulses bilaterally.
- Respiratory: Clear lung fields bilaterally, no crackles or wheezes.
- Abdominal: - Abdominal palpation unremarkable, No big spleen or liver felt, Stomach empty, Bladder empty
- Lymphatic: Slightly up lymph nodes in the back
- Coat and Skin: Sticky from episodes
- Musculoskeletal: Ambulation normal, no lameness observed.
- Neurological: Normal neurologic exam with normal mentation. No proprioceptive deficits or overt ataxia; normal cranial nerve exam.
- Neck and Thyroid: No peripheral lymphadenopathy.
- Reproductive and Urinary: Normal external genitalia, no discharge or inflammation.
- Mammary: No significant findings
- Rectal: Not examined
Assessment
- Chronic diarrhea with hematochezia and urgency, likely originating from the lower gastrointestinal tract.
- Possible dysbiosis or other underlying gastrointestinal imbalance.
- History of Clostridium infection, though not confirmed in recent stool tests.
- Weight loss and decreased appetite, potentially secondary to chronic gastrointestinal distress.
- Low albumin levels, possibly due to protein-losing enteropathy or chronic diarrhea.
- Differential diagnoses include inflammatory bowel disease, gastrointestinal dysbiosis, or other chronic enteropathies.
Plan
- Perform endoscopy under anesthesia early next week to evaluate the gastrointestinal tract and obtain biopsies if necessary.
- Run stool tests for dysbiosis and Clostridium to assess gut microbiota and bacterial balance.
- Prescribe anti-nausea medication to improve comfort and reduce vomiting episodes.
- Continue famotidine twice daily for gastric acid reduction.
- Provide an estimate for the endoscopy procedure and discuss logistics with the owner.
- Advise the owner to monitor stool consistency, frequency, and any additional symptoms until the procedure.
Client Discharge Note
Dear Spencer's Caretaker,
Thank you for bringing Spencer in today. It was a pleasure meeting both of you, and we appreciate the detailed history and observations you provided. Your attentiveness to Spencer's condition is commendable and will help us in determining the best course of action for his care.
Summary
During today's visit, we discussed Spencer's ongoing gastrointestinal issues, including persistent diarrhea, occasional vomiting, and reduced appetite over the past three weeks. You also noted episodes of bloody stool, loud stomach rumbling, and pacing behavior, which seem to indicate discomfort. His weight has decreased from 12 pounds to 9.6 pounds, which is concerning.
On physical examination, Spencer's heart and lungs sounded normal, his abdominal palpation was unremarkable, and his dental health was excellent following his recent cleaning. However, his symptoms and history suggest a need for further diagnostic evaluation to identify the underlying cause of his condition.
Key Topics We Discussed
Medications:
- Continue administering Famotidine (Pepcid) twice daily as it may help with any upper gastrointestinal discomfort.
- we are prescribing an anti-nausea medication to help manage his vomiting and improve his comfort. Please administer as directed on the label.
Dietary Recommendations:
- Maintain a bland diet for Spencer, such as boiled chicken and rice, to ease his digestive system. Avoid any treats or foods outside of this diet for now.
- Ensure he has access to fresh water at all times to prevent dehydration.
Diagnostic Plan:
- We recommend running a stool test to check for dysbiosis (imbalance in gut bacteria) and Clostridium presence. Please bring a fresh stool sample to the clinic on Monday.
- An endoscopy is advised to further investigate the cause of his symptoms. We can schedule this procedure for Monday to move forward with diagnostics.
Monitoring:
- Keep a close eye on Spencer's symptoms, including stool consistency, frequency of diarrhea, vomiting, and appetite. Note any changes or new symptoms.
- If his condition worsens or if you have any concerns before Monday, please contact us immediately.
Comfort Measures:
- Clean Spencer as needed to keep him comfortable and prevent skin irritation from his episodes.
- Ensure he has a quiet, comfortable space to rest and recover.
Thank you for entrusting us with Spencer's care! Please do not hesitate to contact us if you have any questions or concerns.
— Dr Yadav