C10020893 / invoice 10000

12/03/2026 DATE/TIME of CONSULTATION: 01:47hrs, Thu 12/03/26
CLINICIAN: CX
PRESENTING COMPLAINT: haematoemsis
HISTORY:
- Tonight O waked up and noticed she was vomiting blood on the bed, more lethargic than normal
- She also had haemorrhagic diarrhoea when she arrived
- She seemed a bit constipated yesterday.
- UTD with vaccination and deworming
- No potential access to rat bait or other toxins. Carer sometimes took her out for walk and not sure whether she ate something outside. 
- No other medical history. EDDU all normal before today
- Not on any medications

CLINICAL FINDINGS: 
Mentation: QAR HR: 150 RR: 24  MM: pink and moist  CRT: <2s  Temp 38.1. 
- Clear eyes, nose and ears.
- No obvious skin tent
- Heart auscultation nad, no audible murmur or arrhythmia
- Normal respiratory rate and effort, clear BV sound
- Abdominal palpation tense in all quadrants
- Peripheral LNs wnl
- Showing haemorrhagic diarrhoea in consult
- Skin nad
- MSK nad

PROBLEM LIST: Haemorrhagic diarrhoea and vomiting
DIFFERENTIALS: HGE vs toxin vs parasite vs liver vs pancreatitis vs addison's vs coagulopathy vs others

OPTIONS PROVIDED:
1) hospital admission + blood + supportive care + imaging if required
2) outpatient management with blood tests
3) outpatient management with medication trial only
Will go ahead with option 1

DIAGNOSTIC TESTS:
PCV/TP: 57/60
EPOC: Glu 7.1, Na/K ratio 37.4, unremarkable

TREATMENT:
- IVFT 2x maintenance then adjust based on ongoing losses
- maropitant injection 1mg/kg given
- buprenorphine 0.3mL given

CLIENT COMMUNICATION/PLAN:
- Will do supportive care tonight and discuss plan based on her response. O may consider transfer to reg vet if stable enough.

12/03/2026 ******************DAY SHIFT UPDATE****************
PROBLEM LIST:

CLINICIAN:
EXAMINATION:
DIAGNOSTIC TESTS:
You may view the images on Purview, our cloud-based PACS server, via this link:  
ASSESSMENT:
PLAN:
Fluid plan:
Analgesia:
Nutrition Plan:
Monitoring:
- Recheck PCV/TP, EPOC, q24
- Monitor blood pressure q12
-
-

Discharge Criteria
- Pain managed
- Eating without assistance
- Clinically bright

CLIENT COMMUNICATION:
OWNER UPDATED re ACCOUNT:
CURRENT ACCOUNT BALANCE:


******************NIGHT SHIFT UPDATE****************
CLINICIAN:
EXAMINATION:
DIAGNOSTIC TESTS:
ASSESSMENT:
PLAN:
Fluid plan:
Analgesia:
Nutrition Plan:
Monitoring:
- Recheck PCV/TP, EPOC, q24
- Monitor blood pressure q12
-
-

Discharge Criteria
- Pain managed
- Eating without assistance
- Clinically bright

CLIENT COMMUNICATION: