C09991640 / invoice 10000

Recheck from Tuesday

Reason:

History: Swallowing a lot, will only eat with zofran. 
Has had a few bouts of diarrhoea. 
Ate chicken last night. Ate a little kibble this morning. 
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: QAR (anxious but sweet)
Weight: 
Temp: 39.7
HR:  120  
Pulse quality: Normodynamic, synchronous 
MM colour: Pink, moist 
CRT: <2sec
RR: 16
Respiratory effort: WNL
Lung sounds: WNL
Cardiac ausc: No murmurs or arrhythmias 
Abdo palpation: Comfortable, NAD
Gut sounds: 
Rectal: Paste-like, light brown diarrhoea 
EENO: WNL
Skin (including turgor): No facial swelling noted today. Scaling around neck and behind ears. 
LNs: WNL
MSK: WNL (full exam not performed)
NEURO: WNL (full exam not performed)

Diagnostic Information: 
CBC:
WNL

Biochem:
Decrease in amylase

Lytes:
WNL

Treatments given: 
Nil

Assessment: 
Problem List
1. Diarrhoea 
2. Hyporexia 
3. Swallowing  

Plan:
1. Repeat bloods
2. Continue supportive care at home with additional medications 
In Hospital Medication(s):

Exercise: 
Nutrition: 
Medications provided at discharge: 
Zofran 4mg TID 
Paracetomol 20mg/kg PO TID for 5 days
Prokolin 3mls BID until normal stools
Psyllium husk 1.5tsps BID until normal stools 

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