C09972778 / invoice 10000

Reason: V+ D+, Have Tried Chicken And RiceAppointment Notes: BGHistory:Presented for 2x vomits on Friday D+ since Saturday am progressively worsening throughout this time despite being fed chicken and rice Tonight D+ becoming orange and then bloody Not passing copious amounts of diarrhoea No further vomiting since Friday until late this evening No diet change Not a known FB eater No access to toxins No blood present in vomit Tonight no interest in food but then ate at 730pm and vomited it back up Noticable increase in gut sounds this evening Hypersalivating No other health concerns No current medications AHDS episode in 2024, since then one further episode of D+ with no vomiting or inappetence managed with prokolin OTCExamination:Mm pink CRT <2 moist No oral pathology but moderate hypersalivation Submandibular LN normal Eyes and ears NAD HR 104 reg, no murmur or arrhythmia, pulses SSLungs clear no adventitious sounds, RE normal Abdo soft and comfortable, increased borborygmus, no palpable obstruction or focal pain T 38.9 Rectal exam unremarkable Plan:Discussed options including admission to hospital with bloods and imaging and O elects to admit to hospital due to previous episode causing significant dehydration but will wait to pursue full bloods and imaging unless needed PCV/TP 58/58 IVFT started at maintenance Maropitant 1mg/kg IV Prokolin 6mL PO q12 Add paracetamol for pain cover if pain scores high overnightDr NC- Overnight Update:Subjective: QAR, anxiousObjective: Temp 38.3       MM  pink, salivating         CRT <2s         HR 100        FP Strong and synchronousBCS:   5/9                  Pain Score (CSU):   0/4CV:  No murmur auscultated, regular rate and rhythm       RESP: clear bronchovesicular sounds bilaterally. No change to respiratory effort   RR 36GIT:  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 wnlProgress:- Bout of watery/bloody diarrhoea @ 0300- Salivating and appears nauseous on exam- Not interested in food.Assessment: AHDS- recommend continued supportie care over the day.Treatment:1) Trazodone 200mg PO2) Pro-kolin BID3) Maropitant SID4) IVFT-Hartmann's @ 3ml.Kg.Hr5) Ondansetron 0.2mg/kg TIDClient Communication:--- 02/03/2026 05:26:41 NCA:Tried called owner- no answer. Voicemail left to call us back.--- 02/03/2026 11:38:40 AM VIA:Treatment - Resolved - still in hospital    Vital Signs    Weight: 35.1;