C09991428 / invoice 10000

Discharge for Milo

Reason:

History:
Current complaint:
Past history: 
Travel:
Other animals at home: 
Current Medications (including heartworm and flea): 
Presence of toxins (compost, plants, outside yard access): 

Patient Data: 
Physical Examination: 
Weight: 
Temp: 
HR:    
Pulse quality: 
MM colour: 
CRT: 
RR: 
Respiratory effort: 
Lung sounds: 
Cardiac ausc: 
Abdo palpation: 
Gut sounds: 
Rectal: 
EENO: 
Skin (including turgor): 
LNs: 
MSK: 
NEURO: 

Diagnostic Information: 


Treatments given: 

Assessment: 
Problem List
1. 
2. 
3. 
4. 

Plan:
In Hospital Medication(s):

Exercise: 
Nutrition: 
Medications provided at discharge: 

Home instructions: 
Diet and/or exercise restrictions: 

Client Communication: 
Estimate: 
Financial concerns: 

Discharge letter sent to referring vet?   Yes or No  Email 

SHIFT CHANGE: Day             AM/PM        VET IN CHARGE:
Working Diagnosis:
In Hospital Vet Consult entered in Smartflow? YES/NO
Last time Estimate updated and O informed: 
Plan for this shift:
Discharge letter YES / Started /NO

 

ROOM 3
milo - ahds - foley catheter
est. higher end $2200-$3000

Reason:

History:
Coming from Drovers - AHDS 

O said that this morning started to have diarrhoea, that has turned into bloody diarrhoea. Has also been vomiting. 
No changes in diet. 
Nil known medical conditions

Current complaint:
Past history: 
Travel:
Other animals at home: 
Current Medications (including heartworm and flea): due vaccines now, otherwise nil meds
Presence of toxins (compost, plants, outside yard access): nil known toxins 

Patient Data: 
Physical Examination: 
Weight: 16.3kg 
Temp: not taken on arrival 
HR: 124    
Pulse quality: normosynchronous and normodynamic 
MM colour: pink, slightly tacky 
CRT: 1-2 sec
RR: panting 
Respiratory effort: normal 
Lung sounds: normal bronchovesicular sounds, no crackles/wheezes
Cardiac ausc: no murmur/arrythmia 
Abdo palpation: tense 
Gut sounds: slight increase
Rectal: not performed, rectal foley in place  
EENO: no ocular/otic/nasal discharge or lesions 
Skin (including turgor): mild delay in skin tent 
LNs: no palpable enalrgements
MSK: ambulatory, full MSK exam not performed
NEURO: QAR, full neuro exam not performed. Anxious 

Diagnostic Information: 
Drovers bloods 
- CBC 
mild leukocytosis 20.72 (rr. 5.05-16.76) 
mild neutrophilia 17.78 (rr. 2.95-11.64) 

- Biochem 
mild increase ALT 136 (rr. 10-125) 
mild hypokalaemia 3.4 (rr. 3.5-5.8) 

Treatments given: 
5% dehydration Hartmanns IVFT (110mL over 12hrs, reassessment q4hrs)
Prokolin 
Ondansetron 
Paracetamol 
+/- methadone if required
Rectal foley care

Assessment: 
Problem List
1. Acute vomiting 
2. Acute haemorrhagic diarrhoea 
3. 
4. 

Plan:
In Hospital Medication(s):

Exercise: 
Nutrition: 
Medications provided at discharge: 
Ondansetron 8mg wafer - 1 wafer under the lip q8-12hrs as required 30 minutes prior to feeding for anti-nausea. 
Prokolin continue as prescribed by Drovers 
DOSE Paracetamol 500mg tablets - 1/2 tab PO BID for 3 days 

Home instructions: 
Diet and/or exercise restrictions: 

Client Communication: 
Informed O that will continue supportive Tx in hospital. Would like to admit for a 24hr stay, as sometimes these dogs do need longer supportive care. 
Asked O if she would be wanting to transfer to Drovers tomorrow, but O happy to continue treatment here, as he has already been in the car multiple times today. 

Told O that will only call if any concerns o/n, otherwise O to call in the morning for update. 

Male O called 3am for update 
- eaten and no V+
- D+ still bloody but small volume, not even filled the bag yet 
- did have some anxiety, so given some sedation, he got very sedate so had to reverse, and now he is just a bit sleepy. 
- O would like a photo of him, sending through email alfie_123@hotmail.co.uk 

Estimate: $2200-3000 for 24hrs
Financial concerns: nil stated

Discharge letter sent to referring vet?   Yes or No  Email 

SHIFT CHANGE: Day             AM/PM        VET IN CHARGE:
Working Diagnosis:
In Hospital Vet Consult entered in Smartflow? YES/NO
Last time Estimate updated and O informed: 
Plan for this shift:
Discharge letter YES / Started /NO

 

Pt had D++ for last few days, now started V+ last night and bloody D++, not on any medications BAR in reception, aware of wait times. cj

Reason:

History:
Current complaint:
Past history: 
Travel:
Other animals at home: 
Current Medications (including heartworm and flea): 
Presence of toxins (compost, plants, outside yard access): 

Patient Data: 
Physical Examination: 
Weight: 
Temp: 
HR:    
Pulse quality: 
MM colour: 
CRT: 
RR: 
Respiratory effort: 
Lung sounds: 
Cardiac ausc: 
Abdo palpation: 
Gut sounds: 
Rectal: 
EENO: 
Skin (including turgor): 
LNs: 
MSK: 
NEURO: 

Diagnostic Information: 


Treatments given: 

Assessment: 
Problem List
1. 
2. 
3. 
4. 

Plan:
In Hospital Medication(s):

Exercise: 
Nutrition: 
Medications provided at discharge: 

Home instructions: 
Diet and/or exercise restrictions: 

Client Communication: 
Estimate: 
Financial concerns: 

Discharge letter sent to referring vet?   Yes or No  Email 

SHIFT CHANGE: Day             AM/PM        VET IN CHARGE:
Working Diagnosis:
In Hospital Vet Consult entered in Smartflow? YES/NO
Last time Estimate updated and O informed: 
Plan for this shift:
Discharge letter YES / Started /NO