C09993499 / invoice 10000

Reason: Altered Mentation - Stiff And Shaking For 30 MinConsult Time: History: Possible ingestion of Os medical marijuana for Crohns diseaseNo other access to toxins Walked this morning at Currumbin Park 9am-10am Has been previously wellNo history of trauma UTD NGS No other health concerns Only pet in household No raiding of rubbish bin or compost No garden currently as living in a duplexFed lyka diet Subjective: Objective: Temp  38.3          MM pink             CRT  <2           HR  60        FP SSCV:  Bradycardia, no arrhythmia, ECG trace normal RESP:   NAD           RR 40GIT:   soft and comfortable U/G:  urinary incontinence, entire male, testicles NAD Neuro:  altered mentation, hyperaesthetic, no nystagmus, ataxia, withdrawal present, no spinal or neck pain, reduced gag and CP in both HL, no muscle fasciculations M/S:  Good symmetrical muscling and excellent BCS Integ: Skin and coat in excellent conditionOphth:  Pupils dilated but symmetrical, exaggerated menace Assessment: Likely THC toxicity despite negative urine testing, possibility of other neuroligical toxins or primary CNS disease however strong suspicion for marijuana ingestion given clinical presentation Some hypersalivation and lip smacking noted during catheter placement suspected nausea BP stable overnight, ECG trace normalPlan: Admitted for overnight monitoring and IVFT + ECG monitoring If no response to therapy will require further investigations to assess for underlying CNS diseaseProgressive improvement overnight, reduced hyperaesthesia and improving gaitSuitable for discharge in morning  Treatment: IVFT at 30ml/hr Maropitant 1mg/kg IV Consent has been given by the client to proceed with this treatment  -  Yes    Vital Signs    Weight: 6.45;