C09970874 / invoice 10000

Appointment Notes: Special payment terms existSOAP PATIENTVeterinary Assessment and Hospitalisation Record for (Vet initials: CO  Shift time: 0100-0800 )Problem List:- Suspected THC tox vs other tox SUBJECTIVE:Hydration status: WNLPain Scale (1-4):Cardiovascular:  Cardiac auscultation no clinically significant abnormalities, pulse pressures normal and synchronous Respiratory: Thoracic auscultation normal, respiratory rate and effort normal  Gastrointestinal:  Normal gastrointestinal sounds, abdominal palpation comfortableRenal/Urinary: urinating normallyNeurological: no significant abnormalitiesMusculoskeletal: ambulating F/W trial: not offered Diagnostics:ASSESSMENT OF PATIENT:Remained stable overnightNeuro improvement Became aggressive - required alfaxan to remove IVTREATMENT (Fluid Therapy & Medications refer to Smartflow):PLAN:Home in AM CLIENT COMMUNICATION:    Vital Signs    

Reason: Y Maybe High OTBHISTORY:Presented for acute neurological signs. . He refused to eat meat, which he normally enjoys, and seemed unable to open his mouth for it.. He was described as shaking at home and in the car, and being hyper-reactive to stimuli. His behaviour was normal prior to being left alone. Was on a walk earlier Current meds: noneProphylaxis:Pre-existing conditions: History of a broken toe at three months of age.Access to toxins eg. RodenticideEXAMINATION:Body Condition Score: 3/5Pain Scale (0-4): 0/4Hydration status (%): appears clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: Appears dull and sleepy but rousable. He is ataxic but ambulatory. He is noted to be hyperaesthetic, showing an over-reactive response to stimuli.Musculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain- Abdominal: no detectable pain on abdominal palpation, normal gut sounds- Rectal: no detectable abnormalitiesUrinary: NSFReproductive (incl ext genitalia): NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFPROBLEM LIST:- Acute onset of neurological signs (ataxia, lethargy, hyperaesthesia)- Inappetence- Suspected toxin ingestionDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:- Marijuana (THC) toxicity- Mycotoxin (mould) toxicity- Other toxin ingestion (e.g., onion, pesticides, fertilisers)DIAGNOSTICS:PCV: 50 TP: 62 Serum: clear Interpretation: nsf Dog: 37-55%, 50-80g/LCat: 25-45%, 55-85g/LBlood Gas Analysis Results - source: venous Findings:Pco2 38 Interpretation:Nsf Interpretation:Urine drug test, results:Marijuana (THC): -ve Cocaine (COC): -ve Opiates (OPI - Opium & Heroin): -ve Amphetamines (AMP - Speed): -veMethamphetamine MET (Crystal) -ve Ecstasy (MDMA): -ve Tricyclic antidepress (TCA): -ve Barbiturates (BAR): -ve Benzodiazepine (BZO): -ve Methadone (MTD): -ve ASSESSMENT:He has presented for acute onset of neurological signs, including lethargy, ataxia, and hyperaesthesia, following a period of being unsupervised at home. The clinical signs are highly suspicious of a toxicity event. Marijuana toxicity is a strong differential given the clinical presentation and potential access to the plant form in the household. Other potential toxins include mycotoxins , or other household items. Given the rapid onset and specific neurological signs, a toxin is the most likely cause.TREATMENT:Please refer to smartflow for admitted patients.PLAN:He will be admitted to hospital for intravenous fluid therapy to aid in flushing any potential toxins from his system. He will be administered an anti-emetic to reduce the risk of vomiting and subsequent aspiration, given the potential for impaired swallowing with neurotoxins. A blood test to assess liver function may be considered if mould toxicity remains a concern, . He will be closely monitored overnight. If his neurological signs worsen (e.g., progressive dullness, respiratory changes), administration of intralipid therapy will be considered to bind toxins in the central nervous system. The goal is for him to be stable for discharge in the morning, though a longer hospital stay of up to 48 hours is possible in severe cases. Home into owner's care. CLIENT COMMUNICATION:Discussed the high suspicion of toxin ingestion, likely marijuana, given the clinical signs. Explained that dogs are more sensitive to THC than humans and can be affected by ingesting the raw plant. Discussed the plan for hospitalisation, intravenous fluids, and supportive care. Explained the risks associated with marijuana toxicity, including the potential for vomiting and aspiration pneumonia due to an impaired swallow reflex, respiratory depression, and seizures, although the latter is rare. Discussed the use of intralipid therapy as a treatment option if he deteriorates, noting the potential risks such as anaphylaxis and pancreatitis, but explaining that the benefits would outweigh the risks in a worsening patient. Provided a cost estimate for overnight hospitalisation of $1400-$1800. Discussed the owner's pet insurance policy, advised the owner that a pre-approval claim would be submitted to the insurance company. The owner consented to the proposed treatment plan.--- 1/03/2026 1:07:25 AM OTA:Rang and udpated O Home 7am    Vital Signs