C09989202 / invoice 10000

Reason:Hospital Day: 3ICU DAYTIME SOAP day shiftCase Summary:Presented for vomiting on 02/03, treated with maropitant. Represented the following day for inappetance. Small intestinal foreign body confirmed on radiographs. Surgery 03/03 revealed a squeaker toy in small intestine which was removed with a single enterotomy incision. Quite painful post operatively, also highly anxious. Has not been eating in hospital as of yet with a single regurg occurring yesterday, Has some free fluid in abdomen (secondary to surgery/ flushing) vs other. Otherwise bright and alert. Discontinued fentanyl CRI overnight, commenced metoclopramide CRI and gave a single dose of ACP IV to reduce anxiety Current medical management protocol:- Paracetamol 15mg/kg IV q 8hrs - Maropitant 1mg/kg IV q 24hrs (next due 11pm) - Metoclopramide CRI @ 0.04mg/kg IV - Fentanyl dermal patch activated - Hartmanns IVFT @ 61ml/hr- Anxiolytics PO: clonidine TID, fluoxetine SID, gabapentin BID Examination: Subjective: QAR - less lethargic then yesterday, still highly anxious Overall less painful when moving around, palpating, walking, etc. Urinating well, no faecal production Single regurg overnight Driking water readily, keeping down; not eating food Objective: Temperature: 38.3CVS: 140bpm (taken after walk outside, resting overnight between 90-100)Respiratory: 28, normal effort; panting after walking Abdomen: soft, not obviously painful Neurological: NSF LN's:  WNL Fluid therapy: LRS 61ml/hr Laboratory: AFAST - pocket of FF caudal to bladder,  D+ noted in colon; scant FF in between mesentery% Blood gas table - DOGSPCV/TS:	42/60	Serum - clearBlood gas valuesHct:	44.9	%pH:	7.388	(7.366 - 7.453)pCO2:	34.9	(29.0 - 51.3)pO2:	24.5	(28.9 - 59.9)Acid-base statuscBase(Ecf)c:	-4.0	mmol/LcHCO3- (P,St)c:	22.0	(17.0 - 24.0 mmol/L)Electrolyte valuescK+:	3.1	(3.6 - 4.4 mmol/L)cNa+:	148	(143 - 150 mmol/L)cCa2+:	1.33	(1.28 - 1.43 mmol/L)cCl-:	118	(112 - 122 mmol/L)Metabolite valuescGlu:	4.9	(4.4 - 6.8 mmol/L)cLac:	2.3	(0.6 - 1.8 mmol/L)cTbil:		(-20 - 1000 µmol/L)Urea:	6.1	(2.5 - 9.6 mmol/L)Crea:	70	(62 - 105 mmol/L)Assessment: Post-operative care for SIFB. Increased FF in abdomen (similar to as described last night) Inappetance Mild post operative ileus Client Communication: Update 1 (start of shift)- Vet Name: Taneeka Corso- Client Name: Christina - Time: 9am - Medical update: Discussed with owner that not much had changed for Millie over the last 12hrs. In general she seems less painful and more settled, however she has not commenced eating and still has free fluid within the caudal abdomen. Her lactate is lightly increased and her potassium is slightly low. Owner would like to take her home and do a food trial to see if she acts differently in a more comfortable and familiar environment. Advised we could trial doing so, but to be aware that she may need further intervention. As alternative offered sedating Millie and sampling the fluid for cytology, +/- placing NG tube to provide enteral nutrition. Owner has declined this for now, will take her home for a food trial and represent if she is continuing to be inappetant or otherwise unwell. Plan: Discharge this afternoon on the following medications: paracetamol, metoclopramide, and cerenia/maropitant. Remove fentanyl patch tomorrow afternoon/Sat AM at reg vet (or with owner if confident)Discharge sheets and instruction attached to file and provided to owner.    Vital Signs