C10020654 / invoice 10000

Hosp obs - Day (2); Current diagnosis - Diarrhoea, PUO, Anaemia, Heart murmur skin disease

(Pyrexia, Anaemia); Daily plan (Monitor Temp, recheck PCV).


Demeanour   (BAR)  
HR/PR       (168 - )
RR          (40 but purr/meowing - normal effort) Heart murmur 3/6
MM          (cat pink, little tacky) 
CRT         (<2s)         
Tem         (39.2 - 39.7)
Weight      (3.49)

Activity
Litter tray use (Y)
Litter changed  (Y)
Urination       (Y+++)
Defecation      (Y Diarrhoea @ midday) 
Faecal score    (6) 
Not quite enough sample obtained for faecal PCR - continue to collect over the day. - Has catrine in litter tray as other litter just absorbs the D+

Appetite      (Good - social eater.)  
Diet          (Tuna - Tuna only diet trial for skin) 
Amount eaten  (0.75 tin)
Drinking observed (N) fresh water given in AM
Vomiting      (N)

Pain score (2/20 overall comfortable) 

FLUIDS    (hartmann's)
Additives (x)
Rate      (4) ml/hr


DIAGNOSTICS: External Faecal PCR


MEDICATIONS:
Maropitant 1mg/kg SC Q24
Buprenorphine 0.017mg/kg IV Q8
Mirtazapine 1.8 mg PO Q24
Amoxycillin 50mg PO Q12
Start Doxycycline 25mg PO BID

11am- developed stinky diarrhoea. 
Wormed  2 weeks ago. 
Starting on pro-kolin administered PO 5.20pm

ASSESSMENT:  staying in hosp for diarrhoea
Faecal PCR- sending off. 


PLAN: Diarrhoea. 

Increasing Apoquel dose to ONE tablet daily 3.6mg

anaemia- needs repeat haematology in 2-4 weeks. Pro-bnp please

staying in hospital overnight

usually only fed sensitive food. 
Currently elimination diet - z/d but doesnt like it so 2 weeks ago owners got a tuna single protein diet. 
- offer anallergenic. 

was on zyrtec tablet daily. 




 


CLIENT COMMS:
SMS owner  7 am (TJ)    
Client contact: AM  (SKM left msg) initial
                PM  () initial 
Billing  done       () initial
Owner updated  on current  bill () [initial] 
               
Level A care by CVES on  (11.3.26) 1800-0800....  AM/PM)

Nurse Management and Hospitalization 
under veterinary supervision of: (ML) 
Overnight Hospital Nurse: (KMM)
SOAP PATIENT
Current Diagnosis (PUO)

SUBJECTIVE:
Hydration status: (adequate)
Food/Water trial: (Y)

OVERNIGHT OBSERVATIONS:

2109:
MENT (BAR)
LITTER CHANGED (Nil) URINATED (nil) DEFECATED (nil)

0100:
HR (purr), RR (40), MM (p), CRT (<2), TEMP (38.2), MENT (BAR), PAIN SCORE (1)
LITTER CHANGED (n) URINATED (n) DEFECATED (n)
Loves affection.

0200 
Urinated and had diarrhoea, collected both samples and put in GVH lab fridge as sign on cage said collect faeces and there was catrine in litter box

0500:
MENT ()
LITTER CHANGED () URINATED () DEFECATED ()

TREATMENT: 
- Fluid Type:                      (hartmanns)
- Additives:                       (nil)
- Rate to be administered (ml/hr): (4)
- New bag added ?                  (nil)

- Medications (drug, dose (mg) , route, frequency, times given): 
Amoxycillin 200mg tab, 14.245mg/kg, PO, q12, 2109
DoxyC 50mg tab, 7.1225mg/kg, PO, q24, 2109
Pro-Kolin, 2ml, PO, Q12, 0200

ASSESSMENT: (Patient stable overnight. Buprenorphine not dispensed or provided from GVH. )

PLAN: (Return to GVH at 8.00 am )

Hosp obs - Day (3); Current diagnosis (FUO); Daily plan ().


Demeanour   (V BAR)  
HR/PR       (168)
RR          (24)
MM          (pink) [Pink ,Pale, Injected, Cyanotic] [Moist,Tacky, Dry]
CRT         (1)         
Tem         (39.8)
Weight      (3.54)

Activity
Litter tray use (no)
Litter changed  (no)
Urination       (no)  (Cage / walk / other)
Defecation      (no)  (Cage / walk)
Faecal score    () 

Appetite      (excellent)  
Diet          (Tuna) 
Amount eaten  (all)
Drinking observed (no)
Vomiting      (no)

Pain score (0) 

FLUIDS    (hartmanns)
Additives ()
Rate      (4) ml/hr removed at 0900


DIAGNOSTICS:
PCV  TPP    38 / 82

Treatment ()
Other Drugs 
 0700   Generic (amoxil) Dose rate () mg/kg Form (tab) Dose (0.25 of 200mg tablet ) No disp () Brand () 
 0900   Generic (doxycycline ) Dose rate () mg/kg Form (tab) Dose (0.5 of 50mg tablet ) No disp () Brand () 
 Generic (Prokolin) Dose rate () mg/kg Form (oral paste) Dose (bid) No disp () Brand () 


GK morning phone call
Spoke with: Matt

Summary:
- Alice doing well overnight with improved demeanor - bright, vocal, and alert compared to being flat on Tuesday
- Had some diarrhoea early last night but has been good since
- Temperature was elevated yesterday morning, progressed downward through the day, and is high normal this morning
- Eating well and wants to go home
- Discharge planned for 1:00 PM
- Follow-up blood work recommended in 10 days to monitor progress


ASSESSMENT:
PCV normal, so not anaemic
Problem list: D+, Neutrophilia, Fever
DDx: Infection (Bacteria/virus/protozoa), inflammation (Skin/Intestine), auto-immune disease, neoplastic 

Tx: Doxycyclin 25mg bid for 14 days and Amoxycillin 50mg BID for 6 days, Prokolin 2ml PO BID, Mirtazapine as required for appetite stimulant

PLAN: 
Return after 10days for recheck and repeat BT

CLIENT COMMS:
SMS owner  7 am ()    
Client contact: AM  () initial
                PM  () initial 
Billing  done       () initial
Owner updated  on current  bill () [initial]