C09994227 / invoice 10000

******************AFTERNOON SHIFT UPDATE****************
PROBLEM LIST: AHDS - cholangiohepatitis

CLINICIAN: Natalka

EXAMINATION:
see smart flow

DIAGNOSTIC TESTS:
- AFAST  - no free fluid, some hyperechoic
- CBC - non-regenerative anaemia, thrombocytopenia,  monocytosis (neutrophils?); 
- BIOCHEM - SDMA elevated, mild hypocalcemia, hypoalbumenia,  ALP off scale; ALT elevated; Bilirubinaemia 130 (0-15); low amylase and lipase
- EPOC low BUN and urea
- PCV/TP 41/50 icteric

TREATMENT:
IVFT 
Paracetamol stopped
Maropitant 1mg/kg q24h
Ondansetron wafers BID
Denamarin BID

ASSESSMENT:
Icteric
Developed hepatopathy
Haematachexia persists

Proteins holding
Inappetance persists
Jelly haemorrhagic diarrhoea still
Is NPO this am

PLAN:
Continue with supportive care 

CLIENT COMMUNICATION:
O visited today during handover 
Paid off account - need to figure out of paid for todays day hosp already before putting on another
Called Karen with blood results 5:30pm

Overnight update 1800-0600 
Reason for hospitalisation: haemorrhagic diarrhoea, ongoing inappetence and gastric ileus. 
Vx, diarrhoea, inappetence began 1/3. Admitted midnight on Monday 2/3. 
Abdominal ultrasound performed 2/3
NGT placed and single lateral radiographs performed. No obvious obstructive pattern. 

Subjective: QAR/dull.
 
Objective:
Temp: 38.7  MM:  pink and moist   CRT:  <2s  HR: 96 FP:   strong and synchronous    RR: 24
BCS:  5/9               
CV: No murmur or arrhythmia  
RESP:  Clear bronchovesicular sounds and normal respiratory effort             
GIT:  Lip smacks on abdominal palpation. No interest in eating. Passing moderate volumes of brown diarrhoea overnight. GRV increased compared to last night. Lip smacking and silent regurgitation when feeding emeraid through NGT. 
U/G:  Urinating - very yellow/orange. 
Neuro:  Appropriate mentation. Normal CN exam. Normal gait. 
M/S:  NAD
Integ:  NAD
Ophth:  NAD
LNs: No perihperal lymphadenopathy 

Assessment: ongoing gastric ileus and inappetence. Diarrhoea persists but is improving. 

Treatment: 
LRS 30ml/hr 
Metoclop CRI 2mg/kg/day
Maropitant 1mg/kg IV q24
Ondansetron 4mg IV q8
Paracetamol 20mg/kg IV q8
Sucralfate discontinued 

Plan: 
Recommend full CBC + biochemistry, EPOC today + abdominal utlrasound.
Ongoing supportive care.

Overnight night update 1800-0600

Subjective: QAR
Objective:
Temp:  38.0 -> 39.7 -> 39.3 MM:  pink and moist   CRT:  <2s  HR: 104 FP:   strong and synchronous    RR: 16
BCS: 5/9               
CV: No murmur or arrhythmia  
RESP:  Clear bronchovesicular sounds and normal respiratory effort             
GIT:  Comfortable on abdominal palpation. NGT in place - gastric residual volumes decreasing. Occasional non-productive regurgitation overnight. Tolerating emeraid feeding. No interest in eating. Passing small amounts of brown diarrhoea frequently overnight. 
U/G:  Urinating normally. Drinking ++.
Neuro:  NAD
M/S:  NAD
Integ:  NAD
Ophth:  NAD
LNs: NAD

Assessment: Jasper has been clinically stable overnight. His ileus is improving and diarrhoea is decreasing. He remains inappetent but tolerating emeraid feeding through NGT. He spiked a pyrexia in the early morning - ddx pain vs infectious vs primary inflammatory vs other. 

Treatment: 
LRS 38ml/hr w metoclopramide CRI 
Paracetamol 20mg/kg IV q8
Methadone discontinued. 
Ondansetron 8mg po q12
Sucralfate 0.5g q12

Plan: 
Contiune supportive care until eating well. Consider CBC if pyrexia persists. 

******************DAY SHIFT UPDATE****************
PROBLEM LIST:

CLINICIAN:  amz
EXAMINATION:
brighter however still not eating
aspirated 70ml fro NG tube at 10:00 

T was 38.8

DIAGNOSTIC TESTS:
Right lateral xray 
> still large amt gas in stomach, no evidence of a bone in the intestine and not an obstructive pattern

You may view the images on Purview, our cloud-based PACS server, via this link:  
ASSESSMENT:
faint bloody/mucoid diarrhoea at 12:00
aspirated 10ml fluid via NG tube


PLAN:
Fluid plan: twice maintenance
Analgesia:paracetamol q8h
Nutrition Plan:
Monitoring:
- Recheck PCV/TP, EPOC, q24
- Monitor blood pressure q12
-
-

Discharge Criteria
- Pain managed
- Eating without assistance
- Clinically bright

CLIENT COMMUNICATION:

spoke with O at 10:00 he possible ate a cooked chop bone 5d ago
> will xray
he has a sensitive gut and mostly on roo and pumpkin

OWNER UPDATED re ACCOUNT:
CURRENT ACCOUNT BALANCE: