C09983378 / invoice 10000

Appointment Reason: Bloody diarrhoea, Appointment Notes: gcHISTORY- Abby has been having diarrhoea since last night, with the latest episodes containing blood and being dark brown in colour. - She has not eaten for ytd and today - She vomited six days ago.- Meds: Mitazepine t/d SID. Ondansetron 2mg PO yesterday - She was previously on Cortisone, which was stopped two months ago as per Doctor Jenny's advice.- She received an injection for arthritis two weeks ago.- She has a history of gut problems and occasional flare-ups.DIAGNOSIS- Possible gastrointestinal flare-up- Inflammation of the colon wall due to presence of blood in stoolTx: - Cerenia 0.2ml SQ- Ondansetron 2mg PO- Pro-kolin 1ml BID- Depo medrol 0.1ml SQ PLAN- Administer anti-nausea injection and tablet- Give Cortisone injection as not eating. Discussed potential SEs and oral liquid might be better - Provide Pro-Kolin paste to help bind stool- Recheck or follow-up as needed based on response to treatment    Vital Signs    Weight: 2.12;       MMColour: Pink;       HeadEyes: Normal;       Nose: Normal;       Skin: Normal;       Ears: Normal;       Neck: Normal;       LymphNodes: Normal;       Heart: Normal;       Lungs: Normal;       Abdomen: Abnormal (Mild incr in gut sound. No obvious pain );       RectalGenetalia: Normal;       Demeanour: QAR;       Temperature: 38.6;       RespirationRate: 30;       HeartRate: 150;       BodyScore: 4;       DentalGrade: 2;       CRT: Less than 1;