C10025022 / invoice 10000

Reason: AHDSSHIFT CHANGE 2100-0700VET:  Sara BaileyASSESSMENT: N2 in hospital for diarrhoea progressing to AHDSHaemodynamically stable - heart murmur not appreciated this shift. Hydration improvingEating - not interested in food, very nauseousDiarrhoea - passed small volume diarrhoea.TREATMENT PLAN.changes to plan:No changes to planO Contact required overnight? - no Transfer details/stay on/discharge from AES - vetbiz to TVH - PR_____________________________________________________________Case SummaryMillie has been treated/monitored at Animal Emergency Service for acute haemorrhagic diarrhoea syndrome.Overnight, Millie remained quiet, alert, and responsive. She was painful on abdominal palpation with slightly weak pulses and was 5% dehydrated. - Hydration improved, abodminal comfort improved with buprenorphine. Very nauseous.A low grade heart murmur was detected intermittently***A faecal foley catheter WAS NOT placed*** Please refer to _Smart Flow - Flowsheet_ pdf for detailed clinical exam records and hospital notes.Treatments given & when next due are as follows:IV fluids (Hartmann's) at 65mL/hr.- Pro-Kolin 5mL PO. Given at 12:30 AM, next due at 12:30 PM.- Ondansetron 0.5mg/kg IV. Given at 0400, next due from 12.00pm .- Trazodone 250mg PO. Given at 12:00 AM, next due at 12:00 PM.- Pregabalin 75mg PO. Given at 12:00 AM, next due at 12:00 PM.- Maropitant 1mg/kg IV. Given at 8:00 PM, next due at 8:00 PM.- Buprenorphine 0.02mg/kg IV q8h given 4:00 AM, due 12:00 PM- Paracetamol 10mg/kg IV q8h given 5:00 AM, next due 1:00 PMIf you have any queries relating to this case, please call 1300 302 912.    Vital Signs    

Reason: Acute HGEREASON FOR REFERRAL:Ongoing management of Acute Haemorrhagic Diarrhoea Syndrome (AHDS). DIAGNOSTIC SUMMARY:Hospitalised for acute haemorrhagic diarrhoea syndrome (AHDS).Background of an OCD lesion removed from her right humeral condyle one week ago. Has been on meloxicam for four weeks.Abdominal ultrasound today showed a fluid-filled intestine consistent with colitis, with no evidence of thickening or an obstructive pattern.MEDICATION PLAN - WHEN LAST GIVEN & WHEN DUE NEXT:* Pro-Kolin 5mL PO - last given at 12:30 AM, next due at 12:30 PM.* Ondansetron 0.5mg/kg IV - last given at 2:45 PM, next due at 2:45 AM.* Trazodone 150mg PO - last given at 10:00 AM* Pregabalin 75mg PO - last given at 10:00 PM, next due at 10:00 AM.* Maropitant 1mg/kg IV - last given at 8:00 PM, next due at 8:00 PM.Added in - * Buprenorphine 0.02mg/kg IV q8h.* Paracetamol 10mg/kg IV q12h.* Trazodone dose increased to 250mg PO, due 10:00 PMEXAMINATION:TIME: 21:09Mentation: QAR, exhibiting anxiety in hospital.Cardiovascular: HR 96 bpm. GI-II/VI L sided heart murmur auscultated Pulse pressures slightly weak but synchronous.Respiratory: RR 28 bpm. Thoracic auscultation clear sounds bilaterally. Respiratory effort normal. No nasal discharge.Temperature: 38.0°CWeight: 31.5kgAbdo: Painful on abdominal palpation. Normal gut sounds. Faecal staining on perineum and tail.Musculoskeletal: Ambulating normally. No palpable neck, spine, limb or joint pain.Neurological: No significant findings. No cranial nerve or proprioceptive deficits/gait.Eyes/Ears/Skin: Clear corneas, nil discharge or blepharospasm. Clean furcoat, no evidence of otitis.Urogenital: Desexed female. Prepuce/vulva normal anatomy.Lymph nodes: Peripheral lymph nodes normal size/shape and not painful.Hydration/volume status: 5% dehydrated. Mucous membranes pink, CRT <2s.PROBLEM LIST:Acute Haemorrhagic Diarrhoea Syndrome (AHDS)AnxietyASSESSMENT:Fluid-filled intestine consistent with colitis found on ultrasound. No evidence of thickening or obstructive pattern.DDx: ulcerative collitis vs AHDSPLAN:Continue hospitalisation with IV fluid therapy (Hartmann's at 65mL/hr) and supportive care.Monitor vital signs, pain score, hydration, and clinical signs.Continue all prescribed medications as scheduled.Offer bland diet and water.Re-assess in the morning for potential transfer back to the regular veterinarian.Client communication and account update:Discussed plan for overnight hospitalisation and monitoring.Provided estimate for overnight care of $800-$1200, with an additional $500 for potential fluid replacement.Plan to transfer back to the primary care veterinarian (TVH Pass Road) in the morning if appropriate.Mode of transfer:Transfer back to TVH Pass Road in the morning.    Vital Signs    Weight: 31.5;