C09992981 / invoice 10000

Reason: Dog Bite Wound On NeckHOSP PERIOD: 0700-1500 VITALS:HR: 136RR: 20Temp: -MM:  pinkCRT: <2Mentation:  Pain Scale (MGCS): /24 Examination:Cardiovascular: Cardiac auscultation normal, sinus arrhythmiaRespiratory: Clear lung sounds, normal resp rate/ effort. Neurological: NSF, normal gait posture , full neuro exam not performed. Gastrointestinal:- Oral: Oral mucosa appears normal, no lesions noted.- Abdominal: Comfortable abdominal palpation, no furhter vomiting or regurg, keeping food down- Rectal: DNP rectal exam. Musculoskeletal: NAD - no evidence of lameness or pain. Full MSK exam not performed.Ears: NAD - pinnae normalEyes: Eyes clear with no obvious discharge or changes associatedLymph Nodes: NAD - peripheral LNs normal in size, no firm or painful LNs identifiedUrogenital:  passing urine on shift. ASSESSMENT:Recovering well - nausea has improved with time and ondansetron TM PLAN: HOme this evening. See discharge notes    Vital Signs    

    Vital Signs    

Reason: Dog Bite Wound On NeckHospital/Inpatient Hospitalisation Period: 2300-0800History Summary:Dog attack Tuesday 5/3Tracheal tear with mediastinal emphysema, non cardiogenic pulmonary oedema identified on CT scan 4/3 Remains stable in room air and not requiring oxygen support. MARS surgeons recommend conservative management.  Physical Examination @2400  VITALS:HR: 128RR: 24Temp: DNP this checkMM: pink moistCRT: 1-2sMentation: BARPain Scale (MGCS): 2/24 Examination:Cardiovascular: Cardiac auscultation normal. Respiratory: Mild increase to lung sounds bilaterally. Normal resp rate and effort. Neurological: NAD - normal gait, posture and mentation; full neurologic exam not performed.Gastrointestinal:- Oral: Oral mucosa appears normal, no lesions noted.- Abdominal: Comfortable abdominal palpation. - Rectal: DNPMusculoskeletal: NAD - no evidence of lameness or pain. Eyes: Eyes clear with no obvious discharge or changes associatedLymph Nodes: LN NADUrogenital: passing urine on shift. Integument: single small wound ventral neck. Superficial, clean dry. Other:Lexi has regurgitated once at 2300 and again at 0600 Diagnostics:Nil this shift. Assessment: Lexi is stable and oxygenating well on room air. She has normal resp rate/effort. She is keen to eat food. However she has started to have regurgitation, have commenced metoclopromide CRI @0600 and maropitant @2300 She is comfortable and apart from her regurgitation could be considered for discharge. Treatment: IVF LRS Metoclopromide CRI 0.08mg/kg/hr - start Maropitant 1mg/kg IV q 24hrAmoxyclav 250mg PO q 12hrParacetamol 125mg PO q 8hrGabapentin 200mg PO q 8hrTrazodone 100mg PO q 8hrMeloxicam PO - HELD due to regurgitation, can be restarted pending how doing Plan: Monitor regurgitation, may need to change oral meds to IV pending how doing. If regurgitation resolves and eating, consider discharge.    Vital Signs