C10016366 / invoice 10000

SHIFT CHANGE: 2100-0700VET: Dr Megan MartinsASSESSMENT: BAREating very well, no signs of nauseaNo stool passed this shift, normal urinationEuhydrated/euvolaemicPyrexia resolved - T 38.7 @ 0200Mildly reactive to palpation of hipsTREATMENT PLAN:Added paracetamol 125mg PO q8-12h - started @ 0500Transfer back to TVHB via vetbiz for ongoing planGiddles has been treated/monitored at Animal Emergency Service for lethargy, diarrhoea and high temperature following a JPS procedure Overnight he has been stable and bright Please refer to *Smart Flow - Flowsheet* pdf for detailed clinical exam records and hospital notes.Treatments given & when next due are as follows:* Pregablin 25mg: q12hrly, last given 2000. Due 0800* Trazodone 100mg: q12hrly, last given at 2000. Due 0800* maropitant 1 mg/kg IV given @ 2100 5/3* paracetamol 125 mg PO q8-12h given @ 0500If you have any queries relating to this case, please call 1300 302 912    Vital Signs    Weight: 9.5;       

Reason: Post JPS Surgery, Lethargic TodayHx:- Presenting problem: JPS on tuesday, today extremely lethargic & produced mucoid bloody stool. No overt faecal material mixed w defecation. 1x vomit in consult - EDUD: - Current medications: -- Pregab 25mg q12hrly (given 8pm)-- Traz 100mg q12hrly (given 8pm)-- Meloxicam SID - Pre-existing conditions: Hip dysplasia, had JPS. Otherwise nil- Access to toxins: Nil CEx:- Mentation: QAR, dull - MM: Pk, hypersalivation / CRT: 2s- LNN: Peripheral lymph nodes are small and mobile - Optic: Pupils symmetrical and responsive. - Otic: Nil discharge or erythema within the otic canal. - Oral/dentition: G0/4- Cardiovascular: HR 110 = femoral PR, strong and synchronous. No arrythmia or murmurs auscultated- Respiratory: RR . Clear bronchovesciular sounds bilaterally, respiratory effort normal. Nil nasal discharge- Abdominal: Palpation soft and comfortable. Site appears nonerythematous, no herniations, no pain - Urinary/reproductive tract: Genitalia appears normal - Neurological: No neurologically significant findings, no abnormalities of the cranial nerves, no proprioceptive deficits - Musculoskeletal: Ambulatoing normally. No abnormalities with palpation and manipulation of spine, limb or joints. - Integument/Coat: NSF- Rectal examination: Mucoid blood - Temperature: 40- Hydration status: EuhydratedProblem List:Pyrexia - infection, inflammation from sx Lethargy: Relating to pyrexia or diarrhoea Mucoid bloody defecation: Inflammatory/dysbiosis, risks of GI ulceration w meloxicam Diagnostics/Management Plan- Run CBC, biochem, ABL- AFAST, if possible, abdo U/S to assess stomach mucosa for deterioration - Monitor in hosp; antibiotics & pain relief, assess temperature ongoingDIAGNOSTICS Mild normochromic, normocytic anaemia Moderate eosinophilia - nil significanceMild monocytosis - inflammatory, infectious   Mild decrease in BUNAFAST:- Gastric mural thickness: 2.5mm, no acoustic shadowing, normal peristalsis noted.- Intestinal thickness: <3mm, no overt abnormalities, normal peristalsis noted- Bladder in tact, full- <1 free abdominal fluid noted in CC regionPlan:Consider antibiotics. Commence pain relief, cont to monitor. Hand over to overnight vet for ongoing management    Vital Signs    Weight: 8.9;       

Reason: Consult Admit - TenesmusSHIFT CHANGE 0600-1600VET: Eleanor ParkerDay of and reason for hospital treatment: Hospitalised for straining to urinate and lethargy.EXAMINATION:Mentation - Stable and comfortable.Cardiovascular status - Vital signs WNL. Tachycardic when examined, but suspect due to excitment.Respiratory - NAD.Hydration/volume status - Urinating on his own, able to empty bladder. Urine clear, no visible blood. Still mild straining but comfortable and passing good amount of urine.Temperature - Normal.Nutrition - Eating well.Urinated 3x in bed when checked at 0900Urinated approx 10cm patch on puppy pad and some mild strainingBladder approx 1.2cmAbdomen comfProblem list:- Straining to urinate- Lethargy- Suspected bladder foreign body vs urachal remnantASSESSMENT and Differential diagnosis:Stable this morning. Urinating well and comfortable.DDx: urachal remnant, bladder foreign body, other.DIAGNOSTIC SUMMARY PLAN:In-house U/S revealed a linear object in the bladder.X-rays with Omnipaque contrast showed no leakage into the abdomen, no obvious ruptures.Plan is for O to take to GP vet tomorrow for follow-up and to organise further imaging, e.g. CT scan.TREATMENT PLAN:Amoxicillin oral antibiotic Q12h. Next due 2300 tonight.Happy to discharge this morning for O to monitor at home.O to take to GP vet tomorrow for follow-up and further imaging.--- 4/01/2026 10:56:23 AM EP0:EP STO DC at 1200O doesn't have a RV yet as only just got him. Will try to book in with a GP vet on monday and let us know so we can send the medical hx.DC booked for 1200Discharge notes for Giddles:Giddles has been seen at AES for straining to urinate. To investigate this, an in-house ultrasound was performed which revealed a linear object in his bladder. He also had X-rays with a contrast agent called Omnipaque, which showed no leakage into the abdomen, meaning there are no obvious bladder ruptures. The possible causes we are considering include a urachal remnant (a persistent part of a structure from before birth), a foreign object in the bladder, or another cause. A urinalysis indicated a urinary tract infection, and he has been started on antibiotics for this. He is stable, comfortable, and eating well. He is urinating on his own and able to empty his bladder. The urine is clear with no visible blood, and while there is some mild straining, he is passing a good amount of urine. His vital signs, including his temperature, have been within normal limits. Therefore, I am happy for him to be discharged into your care for monitoring at home.Medication:He has been receiving an oral antibiotic, amoxicillin, every 12 hours, with the next dose due at 11:00 p.m. tonight. Next Steps:- Continue to monitor Giddles at home.- Please take him to your general practice vet tomorrow for a follow-up appointment.- Discuss organising further imaging, such as a CT scan, with your vet.- If Giddles goes off his food, seems painful or is straining without passing a good stream of urine, please return for a recheck either at your regular vet if they are open, or at AES.Thank you for trusting us with Giddles care. If you have any questions or concerns about anything we discussed, please do not hesitate to reach out.Warm regards,Eleanor Parker, Veterinarian    Vital Signs