Follow-up Consultation

Recheck Consultation
Presentation:  
Bella, a 5-year-old Labrador Retriever, came to the clinic for a follow-up on her persistent gastrointestinal problems.
Recent targeted history:  
Since the previous visit, Bella's appetite has shown slight improvement, though she still occasionally vomits. Her diet remains unchanged, consisting of a hypoallergenic kibble. Her drinking habits are normal, and urination is regular without any abnormalities. Her stools are slightly firmer, with no signs of diarrhoea. No coughing or sneezing has been noted. Bella has been fasting since last night.
Medications currently being given:  
Omeprazole 20mg, once daily, with the last dose administered this morning.
Targeted physical examination:  
Current weight: 30 kg, stable since the last visit.  
Body condition score: 5/9  
Musculature assessment: Normal  
Thoracic auscultation findings: Clear  
Abdominal palpation findings: Mild tenderness in the lower abdomen  
Vital signs: Heart rate 90 bpm, respiratory rate 20 breaths per minute, mucous membrane colour pink, body temperature 38.5°C
Diagnostic tests performed today:  
Abdominal ultrasound: Mild thickening of the intestinal wall noted.
Diagnostic handling:  
Ultrasound images processed and stored in the clinic's database.
Procedures performed today:  
None
Problem list:  
1. Chronic gastrointestinal upset  
2. Occasional vomiting
Assessment:  
Bella is suspected to have chronic gastritis, supported by the ultrasound findings and her breed predisposition. Labradors are known to have a higher incidence of gastrointestinal issues. The condition is more common in middle-aged dogs. Genetic factors may play a role, and recurrence is possible without dietary management. A hypoallergenic diet is recommended.
Plan (admitted to hospital, going home today):  
Bella is going home today with a new treatment plan. Continue Omeprazole 20mg once daily. Next dose due tomorrow morning.
Communication and estimate:  
Discussed Bella's condition with the owner at 10:00 AM via phone. The owner expressed concern about the vomiting but is relieved by the improvement in appetite. Estimate for today's visit was discussed and agreed upon. Recommended continuing the current diet and monitoring for any changes.
Short term plan and instructions:  
Pending results from the ultrasound will be discussed in the next visit. Recheck in two weeks. Continue fasting before future visits as instructed.
Long term plan:  
Recheck every three months to monitor gastrointestinal health. Continue hypoallergenic diet to prevent recurrence. Monitor water intake to ensure hydration. If symptoms persist, consider referral to a specialist. Regular monitoring of weight and body condition score is advised.