C10015134 / invoice 10000

V+ blood + - still eating and drinking, bright, owner noticed this morning.

Reason: Presented with vomiting and diarrhoea.

History:
Current complaint:
Past history: 
Travel:
Other animals at home: 
Current Medications (including heartworm and flea): 
Presence of toxins (compost, plants, outside yard access): 

Patient Data: 
Physical Examination: 
Weight: 
Temp: 38.7
HR:    
Pulse quality: 
MM colour: Pink/ mildly tacky
CRT: 
RR: 
Respiratory effort: 
Lung sounds: 
Cardiac ausc: 
Abdo palpation: 
Gut sounds: 
Rectal: 
EENO: 
Skin (including turgor): WNL
LNs: 
MSK: 
NEURO: 

Diagnostic Information: 


Treatments given: 

Assessment: 
Problem List
1. Vomiting
2. Diarrhoea
3. 
4. 

Plan: Blood test if no improvement

In Hospital Medication(s):
Maropitant 0.6ml SQ @10:40AM

Exercise: 
Nutrition: 
Medications provided at discharge: 
Zofran
Pro-kolin
Psyllium
Panadol

Home instructions: 
Diet and/or exercise restrictions: Bland diet and psyllium handout provided

Client Communication: 
Estimate: 
Financial concerns: 

Discharge letter sent to referring vet?   Yes or No  Email 

SHIFT CHANGE: Day             AM/PM        VET IN CHARGE:
Working Diagnosis:
In Hospital Vet Consult entered in Smartflow? YES/NO
Last time Estimate updated and O informed: 
Plan for this shift:
Discharge letter YES / Started /NO

 

injury to RFL friday evening. worse today, whimpering and limping

History: 
Signalment: 6m Cavoodle ME
Last Oestrus/Descended Testis: 

Presentation: Winstone was playing fetch last night and ran straight into the side of the door (right side). O got an ice pack and adminiter some meloxicam in the morning. O has been coping well with slight lameness of the right forelimb and vocalisation. O returned tonight and found Winston was not wanting to walk and whimpering, he also turned down a treat which is not like him.
Relevant History: Winston has had right hindlimb lameness in the past when he ran into the O who fell on Winston, which resolve with 2-3 days of medication and rest.
Previous Medical History: No previous medical history reported.

Diet/supplements: Puppy meat and biscuits with rice, turkey and vegetables
Eating/Drinking: Normal eating. normal drinking.
Urination/Defaecation/Vomiting/Regurgitation: Normal urination. No diarrhoea. No vomiting.
Indoor/Outdoor/Exercise: slight decrease energy. Indoor with outdoor access
Bait/Cleaning products: 

Parasite/HW/Vac: UTD
Family: no
Travel: 

Medication (name, amount, last given): 
5.5kg id meloxicam 9am

Patient Data:
Mentation: BAR
Body weight = 5.5kg (BCS 4/9)
HR: bpm
Pulse: good, synchronous
Cardiocirculatory: No murmur or arrhythmia auscultated
RR: bpm
Respiratory: clear respiratory sounds in all lung fields.
MM: pink, moist CRT = 1.5sec
Dental: 
EENO: No ocular, nasal or auricular discharge observed.
LNs: no lymphomegaly
Skin (including turgor): normal turgor 
Abdomen: mildly tense abdomen, likely anxious
Gastrointestinal: No abnormal sounds auscultated
Temperature: ¡C
Urogenital: urogenital examination not performed
Rectal: rectal examination not performed
Musculoskeletal: decrease ROM with palpable pain on shoulder palpation and manipulation with no palpable effusion or crepitus. Normal ROM and no palpable pain, effusion or crepitus in the remaining joints of all limbs. No obvious spinal pain palpated.
Neurological: full neurological examination not performed

Problem List: 
Problem 1: Lameness
DDx: soft tissue injury vs fracture
A: It is difficult to determine whether Winston has a fracture of soft tissue injury given the continual vocalisation, however, Winston was observed moving and placing some weight on the forelimb, therefore, fracture is lessly liekyl though radiographs are necessary to assess. However, given Winston's age and given the trauma reported does not sound severe, he may be over-reacting to palption.
P: Conservative management and monitoring reponse. If Winston does no improve or worsens in 2-3 days, recommend representing for diagostics.

Admitted hospital medication(s):

Exercise: 
Nutrition: 
Other instructions: 
Medications provided at discharge: 

Client Communication: Explained as per problem 1 (P:)
Estimate:
Financial concerns: