C09989006 / invoice 10000

Morning Discharge Summary: 5/3/26 
Vet: Kelly Hedrich

Gypsy has been in hospital overnight. Gypsy  initially presented with the following symptoms: inappetance, lethargy

Patient history summary:
Transfer from BVP
Presented to RVC with 3-4day Hx of inappetance and lethargy
Known GIT sensitivities- current hypoallergenic diet
Bloodwork at RVC- Regenerative anaemia. No auto-agglutination
Platelets OK

Current parasite control
Advocate spot-on monthly

Summary of diagnostic tests performed:
PCV/TP
@1700  29/70
@0800  24/62

Regenerative response and Platelet levels normal on CBC @ RVC

Coags
PT 11 (11-17)
aPTT 88 (72-102secs)

AFAST/TFAST- no pericardial, pleural or abdominal effusions

Differential Diagnosis:
Inappetance 
Lethargy
Regenerative anaemia 
DDx: haemorrhage v haemolysis (loss), reduced production (bone marrow Dz). Inflammatory, parasitic, endocrine, neoplasia

Present medical/surgical plan:
Stable PCV/TP
NI in eating in clinic- O anticipated this
No evidence of free fluid in thorax/abdomen

Treatments: (time and next dose due)
Ondansetron 1.8mg IV. Last dose @1000
Ondansetron 4mg PO q12. Next dose due THURS PM
Maropitant 8mg PO q24. Next dose due THURS 2pm 

Discussion with o - summary;
Updated on progress. Stable overnight
PCV/TP holding
Awaiting external FBE- sent from GAE to Vetnostics

Full clinical details are available in the attached smart flow pdf.

DATE/TIME of CONSULTATION: 16:13hrs, Wed 04/03/26
CLINICIAN: amz
PRESENTING COMPLAINT:
quiet, anaemic

HISTORY:
from BVP
Reason: off food / flat
Reduced appetite since friday - eaten 3-4 table spoons in that time.
Reduced energy since Saturday

on hypoallergenic else bloody D+ / V+ if fed other foods.
No V+ / D+ recently.
O managed to get her to eat a small amount on Sunday. (ate tiny amount Friday afternoon)
Has picked at a tiny amount yesterday / today. boiled rice and tiny amount of kibble
yesterday
Does not chew toys
Urine brought in from yesterday afternoon (too old)- no straining. Not urinating much as not
drinking much.
No access to rat bait

Current medications:
Gabapenin 25mg BID - anxiety and back pain.
O has still been giving to her.

Exam:
mm pink <2 CRT
Grade 2 dental disease
T: 38.17
comfortable abdo palp
HR: 160bpm, no audible murmur / arrythmia
Clear lung sounds
LN: no palpable enlargement
Cerenia given SC at 14:00 

Comp bloods performed- regenerative anaemia- Saline agglutination appears negative to me

CLINICAL FINDINGS: Mentation: HR: 192 RR: MM: slightly pale pink CRT: 2 sec Temp . 38.2
brighter at gae however still quiet
comfortable abdomen

PROBLEM LIST:
regenerative anaemia
inappetant

DIFFERENTIALS:
IMHA
coagulopathy
GHI upset and bleed

OPTIONS PROVIDED:
suggest admit for monitoring of HCT

DIAGNOSTIC TESTS:
PT 88(72-102)
aPTT
PCV/TP 29/70 

aFAST if indicated

FBE to external lab to assess for IMHA

TEST RESULT REFERENCE VALUE from BVP 

RBC 3.67 5.65 - 8.87 x10^12/L L 6.95 6.07
Haematocrit 0.312 0.373 - 0.617 L/L L 0.45 0.374
Haemoglobin 88 131 - 205 g/L L 158 136
MCV 85.0 61.6 - 73.5 fL H 64.7 61.6
MCH 24.0 21.2 - 25.9 pg 22.7 22.4
MCHC 282 320 - 379 g/L L 351 364
RDW 17.4 13.6 - 21.7 % 16.5 14.9
% Reticulocytes 9.4 % 1.7 0.3
Reticulocytes 344.2 10.0 - 110.0 K/µL H 117.5 20.6
Reticulocyte
Haemoglobin
21.9 22.3 - 29.6 pg L 25.9 24.8
WBC 9.46 5.05 - 16.76 x10^9/L 5.26 4.6

DIAGNOSIS:

TREATMENT:
supportive treatment with IVFT and monitor PCV

=========
O/n update LW
1800-0600 

Subjective: BAR
 
Objective:
Temp:  38.4 MM:  pale pink and moist   CRT:  <2s  HR: 160 FP:   strong and synchronous    RR: 20
BCS:  5/9               
CV: No murmur or arrhythmia  
RESP:  Clear bronchovesicular sounds and normal respiratory effort             
GIT:  Comfortable on abdominal palpation. No interest in eating. 
U/G:  Urinating normally 
Neuro:  Appropriate mentation. Normal CN exam. Normal gait. 
M/S:  NAD
Integ:  No echymosis. 
Ophth:  NAD
LNs: No peripheral lymphadenopathy 
AFAST- no ff. No obvious masses. 
TFAST - no pleural or pericardial effusion. 

Problem List:
Mild regenerative anaemia
Inappetence 

Assessment: Gypsy has been clinically stable overnight. She has ongoing inappetence, however owner mentions she would not normally eat in this environment. 
FBE currently pending. 

Treatment: 
Maropitant 1mg/kg IV q24 
Ondansetron 0.5mg/kg IV q8
LRS 6ml/hr 

Plan: 
Await FBE
If PCV/TP holding, consider discharge whilst awating FBE results. 

DATE/TIME of CONSULTATION: 20:10hrs, Sat 11/11/23
CLINICIAN: BLT
PRESENTING COMPLAINT: Unwell, NQR. 
HISTORY:
Went out for a walk this morning
Feces were abit hard and urinated alot. 
Appeared very stressed at home. 
Currently on hypoallergenic diet, has carrot for treats. 
Yelped when picked up today
No physical trauma during walks in the am, supervised all the time. 
Appeared sad. 
No access to toxins at all. 

CLINICAL FINDINGS:
BCS: 4/9
Demeanour: QAR. 
Eyes: Clear BAR, symmetrical, no discharges. 
Oral cavity: gingivitis. 
Cardiopulmonary: Clear BV lung sounds, no murmur on ausc. 
Abdo palp: tensed on abdo palp. 
MSK: ambulatory on all 4s. 
Neuro: Reflexes WNL
Urogen: WNL

PROBLEM LIST:
tensed abdo

DIFFERENTIALS:
Pancreatitis vs dietary indiscretion vs IBD flare up vs others. 

OPTIONS PROVIDED:
1. Hospitalization + diagnostic work up
2. Bloods in house - outpatient tx. 
O opted 2. 

DIAGNOSTIC TESTS:
CBC and Biochem unremarkable. 
mild lymphopenia.
low creatinine. 

CLIENT COMMUNICATION/PLAN:
O to monitor ongoing at home. 
Possible Soft tissue trauma around the tail. No medication indicated today.