Case 2: Jack

Case 2: Jack (Client Information)

General History:

Jack is a 4-month-old male Doberman. You obtained him from a farm about 2 months ago after seeing an ad for puppies online.  Jack has been healthy since you purchased him, until he started having diarrhea about 24 hours ago. He has had several episodes of very soft, large volume, foul smelling diarrhea. Initially the diarrhea was pale in colour, then changed to slightly red.

 

Systems Review:

If specifically asked by the veterinarian, you can give the following information:

  • Attitude: Jack is less playful than normal, this started yesterday.
  • Appetite/weight change: He has not eaten in the past 24 hours, and he looks thinner to you.
  • Water consumption/urination: Drinking more frequently than usual in the past 12 hours, but vomited each time he tried to drink (about 6 times). Not noticed to urinate in last 24 hours.
  • Vomiting/diarrhea: He vomited once yesterday (his breakfast), whenever he tries to drink, and in the car on the way over. Diarrhea started yesterday, and is increasing in frequency (episodes now every hour, although less volume  is coming out this morning compared to last night)
  • Other abnormalities (e.g., coughing/sneezing/etc): He has “big globs of white stuff” in the corners of both eyes which was first noticed a day ago.

Previous medical history:

If specifically asked by the veterinarian, you can give the following information:

  • You have not yet taken Jack to a veterinarian. The person you purchased Jack from said that he did not need any vaccines. No paperwork or records were given at the time of purchase.
  • Jack was a very healthy dog until the past day.

Current Health Status:

If specifically asked by the veterinarian, you can give the following information:

  • Environment: Jack was obtained from a farm when he was about 8 weeks of age. He is the only dog in the house. He loves to go to the off-leash dog park, and he is very playful when he sees other dogs.
  • Diet: You are using the same puppy kibble that Jack was getting before you purchased him. You cannot recall the name but you think the bag is green and has a wolf on it. He receives one cup three times a day. As a treat, you usually give him a bit of meat that you are cooking for your dinner each day.
  • Vaccination & Preventatives: you have not scheduled any veterinary visits for Jack, as the breeder told you that he was already given his vaccines at 8 weeks of age and was dewormed the day you got him.

 

Case 2: Jack (Veterinarian Information)

You are working at an emergency clinic, and this is the first time you are seeing this patient. Jack does not have a regular veterinary clinic listed, so there is no one to contact for medical records. Jack’s owner told the front desk he has never taken the dog to the vet.

Based on the check-in information, you know that Jack is a 4-month-old, intact male, Doberman. He is at the emergency clinic with a 24-hours history of severe diarrhea. While you don’t have access to Jack’s health record or vaccination status prior to the appointment, you quickly check the online guidelines for vaccine recommendations to help you remember the puppy vaccine schedule:

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Clinical Medicine 1: Small Animal Clinical Skills Textbook Copyright © 2021 by Shauna Blois is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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