C10006601 / invoice 10000

DISCHARGE NOTESPRESENTING CONCERNS:- Off balance/trouble walking, tremoring, nystagmusPROBLEM LIST FROM PHYSICAL EXAMINATION:- Verticular nystagmus (abnormal eye movement), head tilt to the right, ataxia (wobbly gait), outer ear infectionASSESSMENT:Vestibular Disease Otitis ExternaThe vestibular system is what gives your pet balance and awareness of spatial orientation. Canine idiopathic vestibular disease is an unknown cause of disruption in this vestibular system causing your pet to lose their balance, unable to stand, head tilt, vomiting and sometimes even circle or roll. These symptoms often appear out of nowhere and can be very distressing to you and your pet. The good news is that Canine vestibular disease can be managed with supportive care and will often resolve over a few days. However, it must also be noted that there can be much more serious causes for these signs such as a brain tumour, seizure condition, middle ear infection or stroke. Supportive treatment includes intravenous fluid therapy to prevent dehydration as often these pets won’t want to eat or drink, anti-nausea medication and nursing care. If your pet doesn’t respond to supportive treatment they may have a more serious underlying condition and will need to be referred to the specialists who can perform imaging of the brain. Prognosis is usually good if they respond to supportive treatment, some pets will be home in a few days while others may take longer. If your pet does not respond to supportive treatment prognosis may be guarded depending on the underlying cause.    DIAGNOSTICS AND MANAGEMENT:Blood gas analysisEar cytologyAnti emetic medications SPECIFIC HOME CARE INSTRUCTIONS  Exercise:In order to facilitate your pets recovery, strict rest is recommended until they are back to full health and then gradually reintroducing walks.  Diet:Your pet has no specific dietary requirements and can return their normal diet once home. Medications:Ondansetron (anti-nausea): Please give 1 wafer onto the gums every 8 hours (three times daily) as needed for signs of nausea secondary to vestibular disease.PMP (Ear infection treatment): Instill 5-7 Drops TWICE daily into BOTH ears for 7 days (until recheck).What to look for at home:1. If your pet shows any signs of vomiting, circling, unable to stand or is otherwise unwell please re-check with Animal Emergency Services or your primary veterinarian as soon as possible. 2. Even if your pet appears to be doing well, it is recommended that they have a check up with your primary veterinarian in 3 daysThank you for trusting Animal Emergency Services with the care of Archie.    Vital Signs    

Reason: Vestibular Appointment 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:Blood Gas Analysis Results - source:Findings:Interpretation:A cellular sample was prepared and stained with Diff Quik.  Microscopic examination demonstrated:    Vital Signs