C09984920 / invoice 10000

Reason: L2/3 - Ran Headfirst Into PoleTime: 0100hrs - 1300hrs.Objective:Bodyweight: 5.5kgDemeanour: TPR: Temp: C, HR:120  = Pulses, RR: 20MM Colour: Pink, CRT: <2secCVS: No significant findings on auscultation. Pulses normal.Resp: No significant findings on auscultation. Normal respiratory rate and character at rest.Abdo/ALI: No significant findings. Comfortable on abdominal palpation.Catheter Site: No significant findings. Catheter patent.Hydration: No significant findings. No evidence of hypovolaemia or dehydration.Neuro: Noted patient lethargic and slower but minimal to no ataxia. No CN deficits noted. Responsive.Diagnostics:Assessment:Patient in hospital QAR Ambulating well with minimal weakness and ataxia as well as good appetite good indication that initial suspicions for TBI may have resolved but ongoing lethargy may suggest that longstanding damage may have occuredCT scan can be considered to investigate further but ongoing supportive care with observation is recommended going forward before further general anaesthesia and imaging. Treatment:Ongoing supportive careReassess tomorrow for potential CT scan if concerned/persistent clinical signs.Plan:Continue hospitalisation and care until stable to be discharged home.--- 04/03/2026 06:20:12 JCL:Sleepy in AM, reluctant to stand with encouragement or tilting sternal. Flop back to lateral recumbency.    Vital Signs    

Reason: L2/3 - Ran Headfirst Into PoleTime: 1300-0100Objective:Bodyweight: 5.8kgDemeanour: obtunded - dull/QARTPR: Temp: 37.0 C, HR:  = Pulses, RR: 32MM Colour: Pink, CRT: <2secCVS: progressively bradycardic, progressively lower BPResp: No significant findings on auscultation. Normal respiratory rate and character at rest.Abdo/ALI: No significant findings. Comfortable on abdominal palpation.Catheter Site: No significant findings. Catheter patent.Hydration: No significant findings. No evidence of hypovolaemia or dehydration.ECG intermittent 2nd degree AV blockDiagnostics:NilAssessment:Patient is obtunded and BP progressively decreased from overnight too high to morning adequate then around lunch time slightly low. Fentanyl has been on a high dose. Tried mannitol first, which didn't affect the BP much, then tried naloxone, HR went from 40-50 to 100-110 for a short period of time then decreased to around 70. The accumulation of opioid likely contributed to the AV block. BP increased to normal. To be monitored whether fully resolve the block/bradycardia. Fentanyl paused. MCGS improved.BP then increased to hypertensive. Consider hypertonic saline vs pain relief.Treatment:See smartflowPlan:Owner to decide whether to 1) x-rays if nothing obvious than CT2) CT directly3) no imaging just based on clinical progressConsider u-cath Pending owner to call back and decide--- 3/03/2026 10:10:50 PM JS0:Time: 1:30-10:30Objective:Bodyweight: 5.8kgDemeanour: QARTPR: Temp: 37.2 C, HR:  = Pulses, RR: 28MM Colour: Pink, CRT: <2secCVS: mildly bradycardic but stable with normalised BP Resp: No significant findings on auscultation. Normal respiratory rate and character at rest.Abdo/ALI: No significant findings. Comfortable on abdominal palpation.Catheter Site: No significant findings. Catheter patent.Hydration: No significant findings. No evidence of hypovolaemia or dehydration.ECG intermittent 2nd degree AV block Diagnostics:NilAssessment:Patient recovered to normal demeanour after cessation of fentanyl and addition of multimodal pain relief (paracetemol IV). When attempting to place u-cath, Benny urinated then tentatively took a small walk around the treatment area. The previously obtunded demeanour was likely due to deep sedation in the face of his fentanyl CRI. His heart rythymn and rate progressed to normal and he was resting comfortably for the majority of the evening. His prognosis is still guarded until imaging (CT) can be performed to ensure he does not have any traumatic injury to the structure of his cervical vertebrae. Treatment:See smartflowPlan:- Owner has been updated with improvement of demeanour- Owner was awaiting confirmation of insurance company whether they will cover cost of CT. Cannot cover cost without financial assistance. Discussed Vetpay which owner will apply for and if can get confirmation of Vetpay approval OR confirmation of insurance company coverage wants to go ahead with CT. Owner to update on vetpay approval tonight. Owner is aware CT available from 4pm tomorrow (tentative pending business of hospital) and patient will need 12 hours hospitalisation post CT for monitoring due to contrast- continue monitoring overnight with plan to CT tomorrow if funds are available otherwise owner aware cannot give prognosis without imaging and may elect to continue monitoring or consider discharge if continues to be stable    Vital Signs    Weight: 5.5;