C10004972 / invoice 10000

08/03/2026 DATE/TIME of CONSULTATION: 11:28hrs, Sun 08/03/26
CLINICIAN: 
PRESENTING COMPLAINT:
HISTORY:
- bowel issues
- soft stool yesterday
- had a different snack to usual throughout the week
- no vomiting
- became inappetent yesterday 
- no issues since visit in June
- no current medications
- little drink in reception but reduced drinking. 
- lethargy 

CLINICAL FINDINGS: 
Sub: BAR
Obj: HR: 84, MM pink, moist CRT<2 T: 38.2
Cardiovascular: Grade 2/6
Respiratory: normal respiratory rate and effort, normal bronchovesicular sounds on auscultation, no visible nasal discharge
Gastrointestinal: soft comfortable abdomen on palpation, no strong repeatable focus of pain
Musculoskeletal: no strong repeatable focus of pain on gentle manipulation of limbs and joints, no notable lameness on walk
Neurological: cranial nerves intact, no notable ataxia
Integument: no obvious lesions
Otic/Ocular: normal ocular and otic structures
Lymph Nodes: no peripheral lymphadenopathy noted

OPTIONS PROVIDED:
1. conservative management w marop and ondansetron
2. Given deterioration following last bout of IBD, which required multiple days of hospitalization, admit for IVFT, monitoring, supportive care. 
3. CBC/biochem and management based on results. 
O opted for option 1. 

TREATMENT:
Maropitant 1mg/kg
Ondansetron 4mg BID for 3 days.

CLIENT COMMUNICATION/PLAN:
RV if not eating by tomorrow morning. 
RV with any vomiting or diarrohea. 

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CLINICIAN: Abby Taylor
HISTORY:
Representing after visiting this morning
Currently fed R/C hypoallergenic
No longer on steroids



08/03/2026 ******************NIGHT SHIFT UPDATE****************
PROBLEM LIST:
1. Vomiting + regurgitation
2. Diarrhoea
3. Lethargy
4. Inappetance
5. 5% dehydration

CLINICIAN: Josie Sinclair
EXAMINATION:
EENO: MM pink and sl. tacky, CRT <2s
Cardio: HR 126, no murmur or arrhythmia
Resp: RR 20, no abnormalities on ausc
Abdo: firm but comfortable, stomach enlarged but palpable
MSK: no lameness or discomfort on palpation
Neuro: QAR, no cranial nerve deficits

DIAGNOSTIC TESTS:
AFAST: no FAF, stomach fluid filled (~10cm) and static, general ileus throughout SI, bladder small (~4cm)

EPOC: NSF

Biochemistry: NSF

Baseline cortisol: 648.92
 
ASSESSMENT: acute onset GI upset with significant ileus - likely flare up of IBD due to diet change. In-patient supportive care indicated due to lack of response to OP care.

PLAN:
Fluid plan:
- 5% rehydration plan - 48ml/hr over 12h (LRS)
GI
- Maropitant 1mg/kg q24h IV (given in initial consult)
- Metoclopramide 0.16mg/kg/hr CRI
- Ondansetron 4mg PO q12h (dispense further vs. O drop back in dispensed meds)
Consider NG tube tomorrow due to large stomach and inappetance
Monitoring:
- Recheck PCV/TP, EPOC, q24
- Monitor blood pressure q12

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

CLIENT COMMUNICATION: nil overnight

09/03/2026 ******************DAY SHIFT UPDATE****************
PROBLEM LIST:
Vomiting 
Inappetence 
IBD 

CLINICIAN: Dr L Pinfold 

EXAMINATION:
U++, F-, B- V-
IV fluids running at 48m/hr and metoclopramide CRI at 1ml/hr  

QAR HR = 160 RR = normal MM = pink CRT < 2 secs Temp = 37.7 

Regurgitation - small burps during examination 
Chest - sounds clear 
Abdo - comfortable on palpation 

DIAGNOSTIC TESTS:
PCV/TP = 
EPOC = 
AFAST - no free fluid, stomach - some peristalsis seen, now 4-5cm in diameter 

You may view the images on Purview, our cloud-based PACS server, via this link:  

ASSESSMENT:
Vomiting 
Inappetence 
IBD 

TREATMENT:
Continue IV fluids at 48ml/hr and metoclopramide CRI at 1ml/hr 
Ondansetron 4mg - Give 1 wafer PO TID - given this morning 

PLAN:
Offered fresh food and water - not interested in eating 
Will continue to try and tempt to eat 

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9:15am - eating small amounts of croc and tapioca 

CLIENT COMMUNICATION: LP phoned owner and discussed progress overnight. Explained that Cino is reasonably bright and happy in himself. He is comfortable in his abdomen and urinating without straining. He has not vomited overnight, but still doing small burps / regurgitations. Owner will come down later this morning to drop off ondansetron tablets and try and tempt Cino to eat. 

OWNER UPDATED re ACCOUNT: Yes 
CURRENT ACCOUNT BALANCE: $119


******************NIGHT SHIFT UPDATE****************
CLINICIAN:
EXAMINATION:
DIAGNOSTIC TESTS:
ASSESSMENT:
PLAN:
Fluid plan:
Analgesia:
Nutrition Plan:
Monitoring:
- Recheck PCV/TP, EPOC, q24
- Monitor blood pressure q12
-
-

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

CLIENT COMMUNICATION: