C10008890 / invoice 30000

Appointment Notes: Special payment terms exist, Overdue remindersHospital day:  2Presented overnight for worsening diarrhoea; linked to possible dietary indiscretion. Recent creatinine indicates IRIS stage III CKD, non proteinuric, non hypertensive. Patient has been managed with IVFT overnight and toujeu insulin 7U SQ BID. Physical examination Mentation:  BAROral examination: mm pink, moist, crt 1 second   Ears; eyes; nose: eyes, nose and ears are unremarkableCardiovascular examination:  HR 120 PR 120, no audible murmurRespiratory:  eupneic, normal bronchovesicular soundsLymph nodes: peripheral lymph nodes are smooth and symmetrical.  Abdominal palpation:  comfortable, no organomegaly or mass effect identifiedUrogenital: no discomfort over palpation of the kidneys. Urinary bladder small and soft.  Rectal:  empty rectumMSK:  strongly ambulatory. No long bone or small joint painIntegument:  appropriate skin tent. Freestyle sensor in place, non erythematous around sensorBody weight 8.0kg Assessment Problem List - acute diarrhoea, resolving- iris stageDiagnostics - blood glucose curve3am: 12.3mmol/l5am: 9.5mmol/l8am: 7.8mmol/l- creat 277u/l, urea 28.9mmol/lAssessment Likely acute diarrhoea following dietary indiscretion. No signs to support pancreatopathy, renal parameters stable. IRIS stage III CKD, stable.Single blood pressure suggestive of hypertension, unclear whether this is situational / stress (hospital environment) or a true finding. To be reassessed at recheck next week and if persistent will require ant ihypertensives - note had adverse response to benazepril so will likely require amlodipine or ARB.Diabetic control has been poor over the past week, however in hospital we are seeing ideal glycemic control with toujeu. A half dose (3U) was administered this morning as Simba is always reluctant to eat while in hospital. Plan Discharge into owners care. Toujeu insulin 7U BID SQ; give 3U if not eating at the time insulin is dueMaropitant 12mg po SID as required for poor appetite, consider increasing to 16mg at next dispenseOndansetron 4mg wafer on gums TID, dose increase. Discontinue this medication first before stopping maropitant.CAlOH: administer 150mg po BID (1/4 of 600mg tablet BID) - best when given with food for phosphate absorption. Prokolin 3ml po BID until normal stool for two daysContinue eye drops as dispensed by ophthalmologyRecheck scheduled on Monday - external CBC / biochemistry- blood pressure- replace freestyle sensor if requiredIf diarrhoea persists beyond 5 days then start metronidazole for 5 days.    Vital Signs    Weight: 8.0;       MMColour: pink;       Temperature: 38.8;       HeartRate: 120;       BodyScore: 5/9;       RespirationRate: 30;       PainScore: 0;       BP: 190;       CRT: 1 second;       

Appointment Notes: Special payment terms exist, Overdue remindersExamination Findings: QAR, vitals as shown on the leftSkin was flexible and MMs were moistAbdomen was comfortable on palpationNot interested in food in the morning. Smears of diarrhoeaLaboratory: In-house dipstick:-BlD: --BIL: --UBG: --KET: --GLu: ++++-Pro: ++-Keu: +-pH 5CGM:3:00...12.3mmol/l5:00...9.5mmol/lTreatment: IVFT Hartmanns 49ml/hrPlan: As previousInsulin was held in the morning as not eating    Vital Signs    MMColour: pink;       Temperature: 38.2;       HeartRate: 100;       RespirationRate: 36;       CRT: <2secs;       

HistoryOver the weekend has had some family over - unsure if the kids might have dropped some foodWas on Pro-Kolin syringe for approx 3 weeks? - stopped this two days ago.Has had Pro-kolin again todayZofran given PO at 3pm - had it twice today as not wanting to eat much - seemed to have perked Simba up when had it.Has been really off and not wanting to eat any food - ate some treats after Zofran. Also had some chicken - tried a smorgasboard of food, but did not seem too keenBG: consistently over 25 at homeDrinking this afternoon and was drinking fineGums responding a bit dryDiarrhoea presentWas flat today - is progressing; was feeling a bit better.Medications:Insulin - Toujeo BID 7IU - has received both doses today at 5am and 5pmAluminium hydroxide - did not receive this todayPro-kolin restarted today?Zofran - 3pmExam:HR: 120 - no obvious murmurs or arrhythmiasT: 39.1*CR: pantingNeuro: appears appropriateIntegument: mild tear staining bilaterally; stools on the back of the rectum - reddy/orange colourDentition: grade 3Abdo palpation: soft and pliable - no cranial/caudal abdo pain.MSK: bilaterally hips have marked reduction in RoM consistent with arthritic changes - also has this in the knees.Skin tent: positive, but potentially could be due to ageCRT: <2sMM: pink but tacky/dry feelingLabs:Crea: 277mmol/LUrea: 28.9mmol/LDecreased since last renal panelElectrolytes:Na: 150K: 3.5Cl: 111Ca: 1.37Lactate: 2.5Glucose: 24.1PH: 7.359PCO2: 34.6BE: -6CHCO3-: 18.5Anion gap: 23.7PO2: 36.5PCO2: 34.6CtBil: <20Assessment:Ongoing chronic intermittent diarrhoeaDDx - open - acute on chronic from dietary indiscretion? Repeat pancreatitis (less likely based on the CSx today), IBD/IBS vs allergies vs otherOngoing chronic diabetes:Currently being managed with medicine and the client - is on 7IU BID of ToujeoOngoing CKD:Grade 3 - Px previously discussed with the ownerPlan:Dt acute diarrhoea and Hx of being flat and limited reserve for fluid loss (CKD + diabetes) elected fluid therapy overnight to try maintain/rehydrate the mild dehydration - assumed <5% based on CSxHartmann's49mL/hour - maintenance 26mL/hour + 5% dehydration + ongoing lossesRepeat BG at 2am and 5am (prior to next insulin dose)Insulin - to receive 7IU as long as BG remains highTo discuss with medicine ongoing for care and management in the morning - owner would like to reconsider metronidazole - RH contacted Cheska and discussed metro as owner keen. Cheska advised that medicine will contact owner re: starting on this but unlikely will start.Presented and seen by Dr     @ Time/DateRegular Vet:    Vital Signs