C09971865 / invoice 10000

Reason: Resp DistressHospital Time Period: Sunday 01/03/2026 6am - 6pmHistory:- Presented on 27/02/2026 with acute dyspnoea and pyrexia (40.1°C).- Diagnosis of severe bronchopneumonia confirmed on thoracic ultrasound and radiographs (bilateral, mid-ventral consolidation).- History of chronic rhinitis.- Initial haematology on admission (27/02/2026) revealed severe neutropenia (0.38 x 10^9/L), severe lymphocytosis, and monocytosis.- Initial biochemistry showed mild hyperglobulinaemia (58 g/L) and azotaemia (Creatinine 222 µmol/L), suspected to be pre-renal.- Echocardiogram has ruled out cardiomyopathy (normal wall thickness and LA ratio).- Is stable but requires oxygen therapy and becomes dyspnoeic with exertion.Subjective:Alert and responsive. Very smoochy, purring, interactive, and rolling on back.Objective:Temp: 38.0°C MM: Pink, tacky CRT: <2 seconds HR: 198 FP: GoodBCS: Wt: 5.02 kgPain Score (CSU): CV:No murmur or gallop audible. BP MAP 64 mmHg (Suntech size 3, left forelimb).RESP: Mild increased bronchovesicular sounds. No crackles or wheezes. SpO2 97% on femoral pulse. RR: 64GIT: Ate approximately 1/4 can of I/D at 05:00. Ate all offered chicken. No defecation noted. Water available.U/G: No urination noted.Neuro: NADM/S: Ambulatory.Integ: NADOphth: NADLNs: NADInternal Laboratory:PCV/TP 33%/92 g/LElectrolytes and stat bloods:CREA 201Haematology:WBC 26.09 (2.87-17.02)NEU 19.52 (2.30-10.29)LYM 4.26 (0.92-6.88)MONO 1.66 (0.05-0.67)Bands suspected.Nucleated red blood cells suspected.Blood smear - consistent with the above.  CRP <1.0 - not elevatedInterpretation (Haematology)- Marked inflammatory leukogram with a mature neutrophilia. Resolution of severe neutropaenia- Monocytosis.- Significant improvement from previous severe neutropenia.Problem List:- Severe bronchopneumonia- Marked inflammatory leukogram- Resolving severe neutropenia- Mild azotaemia- Mild dehydration- Mildly increased respiratory rate and effortAssessment:Clinically improving with resolution of neutropenia. No longer requires oxygen therapy at rest. Prognosis is good. The primary issue remains severe bronchopneumonia.Treatment:- Ampicillin IV- Clavulanate PO- Hartmann's solution (LRS) at 5 ml/hr IV (1/2 x maintenance rate)- Frusemide CRI has been discontinued.Plan:Diagnostic plan:- Haematology has been repeated today. Plan to continue monitoring renal values and hydration status.Therapeutic plan:- Continue IV fluids and antibiotic therapy.- Consider switching to amoxicillin/clavulanic acid IV.- Wean off oxygen therapy as tolerated.Discharge plan:- Anticipated discharge this evening with oral antibiotics.Client Communication:- Spoke to owner at 09:30 on 01/03/2026.- Updated on echocardiogram results which ruled out heart disease.- Discussed the presumptive diagnosis of severe pneumonia and the significant improvement in the white blood cell count, indicating a good prognosis.- Informed that he is clinically improving, non-oxygen dependent, and likely to be discharged this evening.- A long discussion was had regarding finances. An estimate for today's costs was provided, as well as a review of each 12hr hosp period's costs thus far.  .- Reassured owner that pre-approval from their insurance indicates approximately 75-80% of costs should be covered. Explained we cannot contact the insurance company today as it is a Sunday and our information is limited to the pre-approval details.    Vital Signs    Weight: 5;