C10002892 / invoice 10000

History Summary: N1 post-exlap for single gastrotomy, 2x enterotomy for FB removal. O/N costs halved as admission period only included ~6hrs before day vet chargedSubjective:BAR Objective:Temp:     39.6       MM:   Pink, moist           CRT:     <2        HR:   200          FP:   S+S           RR: 24BCS:    3/9                Wgt: 2.9   kg CV:  NAD       RESP:   NAD           GIT:   Comfortable on abdominal palpationU/G:  NADNeuro:  NADM/S:  NADInteg:  Primapore clean with minimal strikethruOphth:  NADLNs: NADProblem List:- Night 1 post-op FB exlap (1x gastrotomy, 2x enterotomy) for linear FB w/ plication- Mild pyrexia Assessment: Comfortable and eating well overnight. Good N1 post-op recovery. No signs of wound breakdown or dehiscence at this time however more likely to occur at days 3-5 post-op.Vocal and chatty but purring and loves a cuddle but very mobileElevated temperature may be dt opioid induced hyperthermia or pain (however appears comfortable on abdo palpation). Less likely infection or other causes but close monitoring recommended given extensiveness of surgery performed (multiple GIT incisions)Treatment: - IVFT LRS @ 8ml/hr- Buprenorphine 0.01mg/kg IV q8- Gabapentin 50mg PO q12/PRNPlan: Diagnostic plan : Serial pain scoresTherapeutic plan : Ongoing analgesia Discharge plan : Consider in AM given good progress overnight Referral plan : rDVM for rechecks in 2-3d, no suture removal required (dissolvable placed)    Vital Signs    Weight: 2.5;       

Hospital Time Period: 07:00 - 17:30History:Acute vomiting presentation, admitted at 02:00 this morning. See prev for details.Subjective: Anxious, growlingObjective:Temp:  not performed on initial assessment until premdicated 37.5)    MM:     pink         CRT:     <2s (once sedated)        HR:          FP:   n, =      RR: 28BCS:   4 /9                Wgt:  2.5 kg Pain Score (CSU):   /4CV: nma ausculted   RESP: normal lung sounds all quadrants, normal effortGIT: thickened git palpable with oblong git structures palpated.U/G:  moderate to large compliant bladder palpated once sedatedNeuro:  nsf, full neuro exam not performedM/S:  nsf, full msk exam not performedInteg:  nsfOphth:  nsfLNs: nad palpatedAXR performed once sedated not charged to client, performed to assist in surgical expectation/planning if any change since earlier initial axrProblem List:Acute vomitingIndiscriminate eaterAssessment: Client communication:Discussed the potential risks and complications of surgery and anaesthesia including anaesthesia associated cpa, haemorrhage, post op infection, seroma, wound dehisence, septic peritonitis, need for further surgery, potential need for multiple enterotomies/gastrotomy or resection and anastamosis depending on material identified and location, prolonged hospitalisation. Advised the estimate remains as advised by PC $2000-6000 for surgery.Louise and Harrison acknolwedged.Updated post-recovery and advised of hypothermia being the only problem with anaesthesia. ADvised of the gastrotomy and 2 enterotomies for the linear fb obstruction from stomach to ileum. Advised no mouse head like or other hard or other fb material identified or palpated and that material in caecum and colon faeceal matter with possible some soft rope material also however no material that is extending from ileum to caecum and thus these mateiral in the caecum should move through.  - A financial update was provided: total incurred costs are $7,173.20.   - Advised on strict rest for 10-14 days. An E-collar is in place. Must be separated from the other cat.   - Advised to remove all toys, especially ropey, fabric, or felt materials, to prevent recurrence. Suggested considering indestructible toys like Kongs, but advised removing all toys is safest. Encouraged laser pointer play for stimulation after the rest period. - Next steps or follow-up actions:   - Patient will remain hospitalised overnight for monitoring.   - The owner is welcome to visit this afternoon and can bring the toy mouse for comparison with the material palpated in the caecum.   - The owner may bring Daphne's usual food or offer a provided bland GI diet during the visit to encourage appetite.Functional ileus possible.Earliest possible discharge tomorrow.Advised mouse head of the toy may have been chewed to small pieces and may be in faeces in the coming days.Owner advised may require some anti axiety or calming agents in the post op period. Trial gabapentin in hospital and owner to see if one can be adminsitered at visit, to start with 50 mg as awake and walking but possible dysophia with ga recovery and thus not wishing to potentially over sedate and prolong complete normal recovery.KS sent update text message to advise skin has pigmentation dark patches, not bruising.Treatment: IVFT LRS 8 ml/hMethadone 0.2 mg/kg IV q6h based on analgesia assessmentGabapentin 50 mg when owners visited 16:30 - 17:00Assessment: History and clinical findings with the axr suggestive of foreign body obstruction, uncertain if single or linear or mulitple and suspect possible gastric and si obstruction on axr. Stable for ga and surgery in current state. Potential risks and complications of ga and git surgery as below.Anaesthesia: Medetomidine 5 ug/kg and Methadone 0.2 mg/kg IV premedication. Alfaxalone intravenous induction, Isoflurane gaseous maintenance anaesthesia. Hartmann's 3 ml/kg/hr intravenous fluid therapy during procedure. Cephazolin 22mg/kg intravenously at induction repeated every 2 hours. Methadone 0.1 mg/kg IV administered intraoperatively.Transversus abdominis plane regional anaesthesia with bupivacaine 2 mg/kg performed preoperatively after initial sterile prep.Oral cavity nsf with no obvious string material in the pharynx, base of tongue, other.Surgery: A routine ventral midline celiotomy was performed. Left of midline in the sc tissue old dissolving suture (suspected from previous ovh). Exploration of the abdominal cavity revealed:Diaphragm- NormalLiver- NormalGallbladder- NormalSpleen- NormalBladder- NormalLeft kidney- NormalLeft adrenal- NormalRight kidney- NormalRight adrenal- NormalPancreas- NormalGI tract- External stomach appearance wnl. External distal duodenum and entire jejunum erythematous and mildly distended with palpable material throughout at the mesenteris side.Stomach contained soft firm irregular material in distal half and filling the pylorus with linear fb material palpable from pylorus to the ileum with another firm thickened material distal jejunum/proximal ileum. Plicated jejunum (almost entire jejunum) and distal duodenum. Gastrotomy performed in avascular section of the distal body and the oblong rope based fb material removed with transection of the ropey material extending distally through pylorus into the duodenum. Gastric fluid was suctioned. This material passed into duodenum fully. No other material palpated or visualised in entire stomach from lower oe sphincter to pylorus. GAstrotomy closure in 2 layers with 4/0 pds continuous sutures both layers.Distal jejunum/proximal ileum just distal to the site of the 2 cm oblong foreign body, enterotomy at antimesenteric border made and the bunched up rope was removed with 2 cm piece of the same rope that extended distally into the ileum readily exteriorised. Proximal rope connection was cut to release this section. Pllication remained in the jejunum with only relief of this at the distal duodenum and the distal jejunum. Distal enterotomy site closed with simple continuous sutures with 4/0 pds.   2nd enterotomy performed in the jejunum to removel the remainder of the rope material which was readily removed. Proximal enterotomy site closed with simple interrupted sutures with 4/0 pds. The mucosa appeared wnl and no other string or rope like material identified. Or palpated.The git from stomach to the colon was palpated 2 further time. The soft material palpated in the caecum was partially milked but no external appearance conern and not distende thus left the remaining material. Colong had faecal material in. No other obvious material palpated.Omentalisation of gastrotomy and 2 enterotomy sites performed.The celiotomy was closed routinely using 3/0 PDS in the linea alba, 4/0 PDS in the subcutaneous tissues and 4/0 pds intradermal sutures.Primapore dressing placedPost operative plan:1) Methadone PRN2) Continue ivft, supportive care, commence feeding with bland wet food3) Recheck at primary care clinic in 2-3 days4) Wound check 10 - 14 days5) Strict rest 10-14 days with ecollar on    Vital Signs    Weight: 2.5;       

Reason: VomitingHisTory:- Presented for two episodes of vomiting post-prandially this evening. Owner reports vocalisation on abdominal palpation at home. Last meal was around midnight.- Fed Royal Canin Kitten diet with no recent changes. Occasionally consumes dental biscuits from another cat in the household. Normal water intake.- Demeanour reported as normal at home.- Strictly an indoor cat. No recent travel.Investigation:- Induced emesis several weeks ago for FB ingestion - successful Prior History:- History of calicivirus as a kitten, resulting in occasional sneezing since. No history of oral ulceration. Known scavenger.Current Medications:- No current medications.Physical Exam:Subjective: Quiet, but alert and responsive. Resentful of abdominal palpation.Objective: Temp: 38.0°C MM: Pink CRT: <2s HR: 200, regular rate FP: S+S RR: 48BCS: 3/9Weight: 2.6kgCardiovascular: No murmur or arrhythmia detected. Strong pulses.Respiratory: Lungs clear on auscultation.GIT: Two episodes of vomiting reported. No diarrhoea. Mild to moderate cranial abdominal discomfort on palpation with a firm, tubular structure palpable in the mid-abdomen.U/G: NSFNeuro: Appropriate mentation.M/S: Ambulatory.Integ: NSF Ophth: NSF LNs: No peripheral lymphadenopathy.INTERNAL LABORATORYPCV/TS: 45/64(Cat: PCV 30-45%, TS 62-81 g/L)Blood Gas (sample type: venous)Abnormal parameters: pH: 7.314, pCO2: 47.0, Glu: 7.1 (H), AG: 12.0 (L) Interpretation:  Mild changes IMAGINGRadiography: 08/03/2026. Abdominal radiographs performed under sedation (butorphanol and medetomidine). Findings include severe gastric distension with gas and fluid. A suspect foreign body is noted within the stomach and possible proximal small intestines. No obvious SI plication/bunching or 2xpopulation noted at this time Problem List:- Vomiting- Abdominal pain- Radiographic evidence of gastric foreign body and gastric outflow obstructionAssessment:The clinical and radiographic findings are highly suspicious for a gastric foreign body causing a proximal intestinal obstruction. While a non-obstructive gastroenteritis or pancreatitis (causing functional ileus) are less likely differentials, the degree of gastric distension is concerning.Treatment:- Sedation with butorphanol and medetomidine for imaging (see Smartflow)- IV catheter placed.- IVFT LRS @ 7ml/hrClient Communications:- Discussed concerns for a gastrointestinal foreign body and the risk of obstruction. Radiographic findings were reviewed with the owner. The possibility of a soft toy (mouse head) ingestion was raised by the owner.Options offered to client:- Option 1 (Gold Standard): Hospitalisation for IV fluids, placement of a nasogastric tube for gastric decompression, and repeat radiographs in the morning to assess for movement. Proceed to exploratory laparotomy if obstruction persists. Cost estimate: $3,000 for overnight hospitalisation, with surgery potentially an additional $3,000-$6,000.- Option 2: Proceed directly to exploratory laparotomy in the morning.- Option 3 (Conservative): Outpatient management with repeat radiographs tomorrow. Discussed risk of masking signs and progression of obstruction.Plan:- Owner elected to proceed directly to exploratory laparotomy in the morning (09/03/2026). They are cost-conscious and would prefer to keep the total cost under $6,000. Owner went home to search for the suspected missing toy and called back to confirm they would like to proceed with hospitalisation and surgery after being unable to locate it.Discussed possibility of referring to lower cost clinic such as LSAH - Os declined- CPR Orders: CCPR Plan:Diagnostic plan: Proceed to surgery in AMTherapeutic plan: Hospitalise on IV fluids overnight. Plan for exploratory laparotomy on 09/03/2026.Discharge plan: Post-operative recovery and monitoring.Referral plan: Nil --- 08/03/2026 03:47:24 PCP: Clinical update:- Phone call with owner (Harrison) to discuss Daphne's status and ongoing plan. Owner is keen for Daphne to remain hospitalised.Treatment options discussed:- Plan for tomorrow involves either a repeat X-ray to assess progress or proceeding directly to surgery. - Discussed possibility of transfer back to their primary care veterinarian after the public holiday if ongoing care is required.- Option to defer placement of a nasogastric tube for gastric decompression until immediately prior to surgery tomorrow. This would reduce costs by approximately $500.- Alternative option of transfer to another facility (Lort-Smith) tomorrow was mentioned if the owner declines surgery here.Financial Update:- Current costs for hospitalisation, diagnostics, and attempts to decompress the stomach are estimated between $2,500 and $3,000.- Estimated cost for surgery tomorrow is between $3,000 and $6,000. A definitive plan and cost will be confirmed with the owner in the morning.- Total estimated cost for surgery and post-operative recovery (1-2 days) is between $6,000 and $8,000, assuming no major complications.- The owner was advised that complicated foreign body surgery cases can globally cost up to $10,000. The minimum cost for surgery and initial hospitalisation is approximately $6,000.- A deposit of $1,500 is required tonight to proceed with further care.Communication Plan:- A consent form will be emailed for signature.- The owner will discuss the financial estimates with his partner and call back to confirm the plan.- The clinical team will provide updates at least twice daily.--- 08/03/2026 04:03:24 PCP: Over the phone updateTreatment options discussed:- Plan is to proceed with exploratory laparotomy for a suspected foreign body.- Discussed the risk of a negative exploratory surgery, but this would provide certainty.- Post-operative hospitalisation is anticipated to be 1-2 days.- Discharge criteria discussed: eating, comfortable on oral medications.- Early discharge may be considered if anxiety in hospital is impacting recovery.Financial Update:- Acknowledged owner's concerns regarding costs. Will be as cost-conscious as possible. - A deposit of $1500 was taken over the phone.- Post-operative hospitalisation costs will be communicated to the owner before they are incurred.Communication Plan:- Consent forms to be emailed to the owner.- The team will provide an update in the morning before the procedure to confirm the timing. The procedure is anticipated to occur in the morning hours, but delays are possible in an emergency setting.- An update will be provided later this morning on Daphne's progress.    Vital Signs