C10006031 / invoice 10000

SUBJECTIVE:Presenting Concerns:  George Christensen presented for ongoing vomiting. He was seen last week for this issue and discharged on medication but has continued to vomit. Overnight, he vomited ingesta that was consumed over 12 hours prior. He is also reported to be extremely dull and lethargic.    Historical Conditions:  The patient was seen last week for vomiting. A full blood gas and abdominal ultrasound were performed, and a pancreatitis test was negative.    V/D/C/S:  The patient has continued to vomit despite medication. He vomited overnight, and the vomitus contained food eaten more than 12 hours previously.    Current Medications:-   Was prescribed Losec, paracetamol, and metoclopramide after his visit last week.  Additional Information:-   The patient is extremely dull and lethargic compared to his normal self.  OBJECTIVE:Weight: 6.4 kg  Mentation: Extremely dull and lethargic  BCS: --/9  T: 38.4 °C  P: 100  R: 24  MM: Dry and tacky. CRT 2 seconds.  Hydration: Dehydrated    Emotional Assessment: Very dull and quiet, which is a significant change from his normal temperament where he typically vocalizes when handled.    Eyes: Clear. No discharge or erythema OU.  Ears: Clean with no discharge or erythema AU.  Nose: Clear, moist without discharge.  Throat: No inducible cough upon tracheal palpation; no palpable masses.  Oral: Calculus and gingivitis absent. No masses or other lesions.  Cardiovascular: No murmurs or arrhythmias, strong synchronous pulses.  Respiratory: Normal bronchovesicular sounds bilaterally.  Abdominal: Significantly sore on palpation, which is worse than last week. The pain is generalized but more pronounced over the cranial abdomen.  Lymph Nodes: No peripheral lymphadenopathy.  Integumentary: Feels warm to the touch externally. No evidence of ectoparasites, full coat with clear skin.  Neurologic: No ataxia.  Musculoskeletal: Ambulation normal, no lameness observed.  Urogenital: Normal external anatomy.  Rectal: Not performed.    Point of Care Diagnostics:-   Abdominal Ultrasound:-   Findings are highly suggestive of pancreatitis.-   There is distinctly hyperechoic mesentery in the region of the proximal duodenum.-   The left limb of the pancreas appears distinctly bright (hyperechoic).-   The duodenum is moderately full of liquid ingesta with a slightly thickened mucosa (diameter approximately 8 millimeters).-   Significant gas is present in the duodenum, which made complete visualization of the pancreas difficult.-   The stomach wall subjectively appears thick but measures within normal limits at 3.8 millimeters. It contains liquid ingesta and appears to have normal motility.-   There is some swirling of contents at the gastric outflow tract.-   The bladder contains anechoic contents with no abnormalities noted.-   No free fluid was visualized in the abdomen.-   The patient was distinctly uncomfortable and painful during the scan, especially with pressure over the cranial abdomen.  ASSESSMENT:Pancreatitis - The clinical signs of persistent vomiting, extreme lethargy, and severe, painful cranial abdomen, combined with abdominal ultrasound findings of a hyperechoic mesentery and bright pancreatic tissue, are strongly indicative of pancreatitis. This is despite a negative pancreatitis test last week.    Dehydration - Secondary to vomiting and likely reduced intake, as evidenced by dry, tacky MM.  PLAN:Medications/Treatments:-   The owner was updated on the ultrasound findings.-   IV fluids were initiated with a 20 ml/kg bolus administered over 30 minutes, followed by a constant rate infusion at 1.5 times maintenance.-   IV analgesia was administered, including:    -   Temgesic at 0.02 mg/kg.    -   Paracetamol at 20 mg/kg.-   A 25 ug fentanyl patch was applied for ongoing pain management.-   IV maropitant was administered at 1 mg/kg for anti-emesis.-   By the end of the day, the patient had good urine output, but MM remained tacky and he was still lethargic. His abdominal pain was noted to be reduced.  Diet & Feeding Recommendations:-   The current c/d diet has been temporarily ceased.-   The patient will be started on plain boiled chicken for a few days.-   He can return to the c/d diet thereafter.  Additional Discussion:-   The patient will be hospitalized for ongoing IV fluid therapy and monitoring. Re-presentation for continued care tomorrow is planned.    Vital Signs