C09971452 / invoice 20000

Hospital Time Period: 1830-0700History: See previous for full details- Night 1 hospitalisation for V/D and inappetance- BAR since Admit, has eaten and no V/D so farSubjective: BAR, anxiousObjective: Temp  38.5      MM  pink          CRT <2s         HR  128      FP Strong and synchronousBCS:   4/9                  Pain Score (CSU):   0/4CV:  No murmur auscultated, regular rate and rhythm       RESP: clear bronchovesicular sounds bilaterally. No change to respiratory effort   RR pantingGIT:  Comfortable on abdominal palpation.U/G:  Bladder soft and not painful on palpationNeuro: alert mentation, no ataxia or weakness. Full neurological assessment not performed.M/S:  No lameness. Full musculoskeletal exam not performed.Integ:  Normal skin tent, no sign of ectoparasites.Ophth:  No ocular discharge or inflammationLNs: peripheral ln wnlLaboratory:- Na 147 (wnl)- Cl 114 (wnl)- K 3.5 ( low)KCL 20mmol/litre added to IV fluidsProgress:- Eating food when offered- No vomiting- No diarrhoea- QAR/anxiousAssessment: GastroenteritisTreatment:1) Ondansetron 0.2mg/kg TID iv2) Prokolin 3ml BID PO3) Trazodone 25mg BID/TID4) Maropitant 1mg/kg SID5) IVFT- Hartmann's @ 3ml/kg/hr + 20mmol/L KClClient Communication:--- 02/03/2026 05:34:37 NCA:Updated owner. Advised stable overnight, eating with no V/D. Happy for him to go home this am. Discharge booked for 0900.    Vital Signs    

Reason: Still Not BetterAppointment Notes: Overdue remindersConsult Time: 1443HISTORY:Leo presented for re-evaluation two days after an initial consultation for bloody diarrhoea and vomiting. The owner reports continued lethargy, anorexia, and inappetence since the last visit. He was drinking some water last night but has stopped. There has been no further diarrhoea observed. However, he has had several more episodes of vomiting clear fluid today. The owner noted that a squeaker from one of his toys appears to be chewed up, raising concern for potential foreign body ingestion as he has a history of destroying toys. He had a dry heaving episode, and the owner reports abdominal sensitivity on touch. There is no coughing. Bowel movements last night were still runny but not bloody. He is not a fussy eater but has refused food.Regular Vet: GX Capalaba. Maropitant injection administered last night Current meds: none.Vaccination: UTD.Parasite Prevention: UTD.Pre-existing conditions: none.Access to toxins eg. Rodenticide: none.EXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: 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: not gradedAbdominal: mild discomfort on palpationRectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: Quiet but responsive. Showed interest in food (chicken) when offered during the consultation and ate some.PROBLEM LIST:Vomiting (clear fluid)History of bloody diarrhoeaAnorexia and inappetenceLethargyPotential foreign body ingestion (toy squeaker)Mild abdominal painDIAGNOSTICS:PCV/TS 50/68CBC MON% 1.8 LOW BIOCHEM NSF ELectrolytes K 3.7 LOW ASSESSMENT:Gastroenteritis (haemorrhagic)Foreign body obstructionTracheitis/Kennel Cough (less likely, but considered due to retching)Vs other TREATMENT:1) ondansetron 0.2mg/kg SIV TID 2) LRS@3ml/kg/hr 3) prokolin 3ml PO BID 4) maropitant 1mg/kg IV SID PLAN:Two options were presented to the owner:1. Outpatient trial: Continue with medical management at home. Monitor for continued vomiting, ability to retain food, appetite, and bowel movements.2. Admission for inpatient care: This would involve intravenous fluid therapy, blood tests, and supportive care, with a plan for imaging (abdominal ultrasound) tomorrow morning if there is no improvement.The owner has opted to 2. CLIENT COMMUNICATION:Discussed the two options for management: outpatient trial versus hospitalisation. Explained that while he is eating, the key factors will be whether he can keep food down and if he continues to eat. The possibility of a gastrointestinal obstruction due to chewing on toys was discussed, and the recommendation for an abdominal ultrasound tomorrow was made if signs persist. The importance of monitoring his clinical signs closely was emphasised. A treatment plan was provided to the owner.--- 01/03/2026 19:31:32 CD5:Updated on bloods and clinical status - bright - no further vx or D+ at this stage - discussed if would like to pursue with US - O happy to hold off if dog doing well - will defer to overnight hospital vet's dvice Next update in AM Handed over to hospital o/n - cont hx ##############################Hospital (NC) - see next entry    Vital Signs    HeartRate: 120;       RespirationRate: 32;       CRT: 2;       MMColour: p/t ;