C09999660 / invoice 10000

DISCHARGE NOTESPRESENTING CONCERNS:- Right forelimb pain at home- An episode of diarrhoea this morning.- Restless and sleepless overnight.PROBLEM LIST FROM PHYSICAL EXAMINATION:1. Acute diarrhoea.ASSESSMENT:Suspected musculoskeletal pain, possibly related to soft tissue injury or a recurrence of previous spinal issues but unable to elicit any pain response in consult. The acute diarrhoea may be stress-related or indicative of a primary gastrointestinal issue. Trialing pain relief for possible pain.TREATMENT/MANAGEMENT:- Trial of pain relief- Strict rest at home- Recheck with primary vet next week or sooner if concernedPLAN:- Discharge home with oral pain relief.- Strict rest and monitor closely at home.- Re-present if signs worsen or fail to improve.Medications for Administration:- Gabapentin 100mg - Give 2 capsules TWICE daily for up to 5 daysHOME MEDICATIONS:Paracetamol 500mg - Give 1/4 tablet TWICE daily for up to 5 daysSPECIFIC CARE INSTRUCTIONS:- Strict rest and light duties.- No rough games or play.- If lameness/pain persists after the course of medication or if the diarrhoea worsens, further investigation would be recommended.The Animal Emergency Service advises a reassessment with your regular vet within 48 hours to monitor your pets progress if there has been no improvement. 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 regular vet immediately.Thank you for trusting the Animal Emergency Service with the care of Frankie    Vital Signs    

Reason: Spinal PainAppointment Notes: Special payment terms exist, Overdue remindersHISTORY:Current meds:Prophylaxis:Pre-existing conditions:Access to toxins eg. Rodenticide:TRIAGE:HR:RR:Temp:Mm: Crt:Mentation:Pain Scale (0-4):Hydration status (%):EXAMINATION:Body Condition Score: Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4):  - Abdominal: no detectable pain on abdominal palpation, normal gut sounds- Rectal: no detectable abnormalities, faeces:  Urinary: NSFReproductive (incl ext genitalia): NSFIntegument/Ears: NSFLymph Nodes: peripheral lymph nodes normalEyes: NSFPROBLEM LIST:DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:DIAGNOSTIC/MANAGEMENT PLAN:DIAGNOSTICS:ASSESSMENT:TREATMENT:PLAN:CLIENT COMMUNICATION:------------------------------------------------------------------------CLIENT DISCHARGE NOTESPRESENTING CONCERNS:PROBLEM LIST FROM PHYSICAL EXAMINATION AND HISTORY:ASSESSMENT:PLAN/DISCUSSION:TREATMENTS ADMINISTERED:Medications for Administration at Home:SPECIFIC 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 regular 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 your pet.    Vital Signs