C09999063 / invoice 10000

HISTORY:Lulu acutely stopped being able to blink with her right eye, her right ear is droopy as well. Otherwise bright, alert and responsive, eating and drinking, no vomiting or diarrhoea.Current meds: nilProphylaxis: UTDPre-existing conditions: left eye often weeps a lotAccess to toxins eg. Rodenticide: nilTRIAGE:HR: 200RR: 24Temp: not takenMm: pinkCrt: <2Mentation: BARPain Scale (0-4): 0Hydration status (%): hydration clinically adequateEXAMINATION:Body Condition Score: 4/9Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: suspected CN nerve 7 paralysis as she is unable to blink with right eye and has droopy ear on the same sideMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4):  2- Abdominal: no detectable pain on abdominal palpation, normal gut sounds- Rectal: no detectable abnormalities, faeces:  normal Urinary: NSFReproductive (incl ext genitalia): NSFIntegument/Ears: NSFLymph Nodes: peripheral lymph nodes normalEyes: NSFPROBLEM LIST:unable to blink with right eye and has droopy ear on the same sideDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Idiopathic facial nerve paralysisMiddle ear infection or other diseaseTick paralysisSnake envenomationBotulismDIAGNOSTIC/MANAGEMENT PLAN:Intraocular pressure:- right: 18- left: 17Anaesthesia: Local Corneal with TetracaineA fluorescein stain was performed, the findings of this test were:- Left: no significant abnormalities- Right: superficial corneal ulcerEar examination:- no significant abnormalitiesASSESSMENT:Suspected idiopathic facial nerve paralysisTREATMENT:1.00 x Viscotears Liquid Gel 10gApply ONE drop to the RIGHT EYE MINIMUM 4 times daily.1.00 x Tricin Ointment 4gApply to RIGHT  Eye TWICE Daily.Discontinue if Irritation Occurs & Contact Your Veterinarian.PLAN:Lulu is going home with eye drops to treat the ulcer and viscotear to protect the eye. Reassessment on Monday if no improvement we recommend seeing an internal medicine specialist.    Vital Signs    

    Vital Signs    

CLIENT DISCHARGE NOTESPRESENTING CONCERNS:Lulu is a 5yo FS DSH Lulu presented to AES @2200 on the 05/01/24 for a history of vomiting and lethargy. PROBLEM LIST FROM PHYSICAL EXAMINATION AND HISTORY:Vomiting Inappetence Dehydration Lethargy ASSESSMENT:Fur ball intestinal foreign body - moving throughPLAN:Going home for food trial.Medications for Administration at Home:Name          Dose              Frequency   number dispensed    Next DueNilSPECIFIC HOME CARE INSTRUCTIONS:The Animal Emergency Service advises a reassessment with your regular vet within 48 hours to monitor your pets progress.  If your pet's condition deteriorates or they become flat or lethargic, go off their food and water, develop vomiting or diarrhoea or if you have any concerns please contact the Animal Emergency Service or your primary vet immediately.If your pet is going home and has a pressure wrap over where an IV catheter was placed please remove it within 20 minutes of leaving the hospital.Thank you for trusting the Animal Emergency Service with the care of Lulu.    Vital Signs