C09983456 / invoice 10000

Reason: Poss FBHospital Time Period:  0600 - 1800History:Ongoing hosp for post-op ex-lap, 1x jejunal enterotomy to remove a FB (rock).Out of GA ~0400AM See prev records for more detail.Subjective:QAR -> BARAnxious in hospObjective:Temp: 38.5           MM:  pink            CRT:  <2s           HR: 120            FP: fair, sync             RR: pantBCS:    5/9                Wgt:   17.4 kg Pain Score (CSU):   1/4CV: no obv murmur or arrhythmias audible, no pulse deficits  RESP: clear  BV Sounds bilat, RE and RR adequate at restGIT: abdo palp mildly tensed around coeliotomy site as expected, defecated soft brown faeces. Not showing interested in RC hypoallergenic. Ate chicken eagerly when offered towards end of this hosp period. U/G: urinated on walks, grossly wnlNeuro: nil ataxia, BARM/S: ambulatory x4Integ: mild strike through over primapore, replaced w a new dressing. Recent coeliotomy site looks adequate, nil discharge.Ophth: nsfLNs: nsfINTERNAL LABORATORYPCV/TS: 44/70	Blood Gases:pH 7.349PCO2 41.0HCO3 21.8BE -3.1Electrolytes:Na+ 149K      3.8Cl    117Glucose 5.3  Lactate 0.8Ionised Ca 1.35Urea 2.4Crea  53Problem List:Post-op ex lap/enterotomyAssessment: Patient recovered well from GA, and remains cardiovascularly stable. P's had been on diet trial for known GI issue, consider hypoallergenic diet/hydrolysed diet to minimise risk of compounding GI symptoms. LOP appears adequate w current regimen, and P has begun showing interest in foods. Titrating fentanyl CRI rate down, and see if can manage LOP w PO meds. Treatment:IVF w Hartmann's @46ml/hrFentanyl CRI @ 3 mcg/kg/hr -> 1 mcg/kg/hrMedetomidine CRI @ 1mcg/kg/hrMaropitant 1mg/kg IV slow q24hrParacetamol 250mg PO q12hrPlan: Diagnostic plan : monitor radiometer, pcv/tpTherapeutic plan : as aboveDischarge plan : when eating and drinking, adequate LOPReferral plan : n/a Client Communication:--- 03/03/2026 09:06:57 JIL: STO, updated O on Pepper. O called and asked if O should bring in Lyka goat diet, since Pepper is currently on diet trial. Adv O that will recc keep Pepper on bland diet w anticipated GI upset from the current FBO/enterotomy, will attempt to feed hypoallergenic diet. O to call back if not heard by 1700.--- 03/03/2026 16:48:33 JIL: STO, updated O on Pepper, doing well so far, gotten more brighter throughout this hosp period and adequate LOP w current regimen. Pepper has been refusing RC hypoallergenic foods until this time, and when bribed w some pieces of chicken, Pepper ate these really enthusiastically. Have commenced PO analgesia, and started to wean down injectable analgesia. Suggested O to visit around 2000PM and see if Pepper will eat RC hypoallergenic, and LOP is adequately controlled.    Vital Signs    

Reason: Poss FBHospital Time Period: 1800-2200History:History of foreign body removalHas been doing well during the daySee previous history for detailsSubjective:BARObjective:Temp:   Did not obtain         MM:  Pink            CRT:    <2         HR:    80 BPM         FP: Normal and synchronous             RR: 30 BPMBCS:    5/9                Wgt: 17.4   kg Pain Score (Glasgow pain score):  2 /20CV:  Normal Heart Rate. No murmurs, no pulse deficits. Average MAP=      Did not obtain RESP:   Lung sounds are normal.  No coughing, no dyspnea SPO2= Did not obtain GIT:   No vomiting or diarrhea. No obvious pain on abdominal palpationU/G:  Unable to palpate a bladderNeuro:  Basic cranial nerve exam is normal. MGCS=18M/S:  NADInteg:  NADOphth:  NADLNs: Lymph nodes are normal sizeProblem List:Post-op enterotomyAssessment: HAs been doing very well after surgeryNo vomiting or diarrheaIs eating wellSince is eating well and pain seems controlled, we are going to trial at home. Owner would like some sedatives to keep her quiet at home Treatment:IV fluid therapyHartmann's @ 46 ml/hrMedications to go homeParacetamol 250 mg PO q 8 hoursTrazadone 50 mg PO q 12 hours as neededGabapentin 300 mg PO q 12 hours as needed.Ondansetron 8 mg PO q 12 hours Plan: Diagnostic plan :No diagnosticsTherapeutic plan :as described aboveDischarge plan :Hme at 2300 Referral plan :None at this time.    Vital Signs