C10028320 / invoice 10000

Admitted: fluids for the day

Still off. 
Syringed 400ml lectade ysterday. 
Ate yesterday morning but hasn't wanted to eat anything since. 
Had vomited Saturday and Tues. Had prevomax last 2 days. 
Haven't seen any difference in him with the prevomax or pain relief. 
O describes as different to his norma tummy upsets - normally hear gurgling and bloody. Vomting food but normally bile and bloody. 
Had 10mg metocopramide the other day. Pred 2.5mg yesterday - normally responds to pred but hasn't. 
Bit lethargic. Defaecated this morning - soft but formed and very yellow. 
Hasn't been drinking voluntarily so want to try him on fluids


Addison's has been mentioned but haven't been able to keep him off pred long enough to test. Did have a stress leukogram yesterday though. 

Bloods all wnl - neutrophilia the other day resolved. POtassium back within range

PE:
BAR. Gets bad separation anxiety and also tries to chew fluid lines.
HR 100.
MMs pink, moist, CRT 2 secs
RR: pant
T 38.7
Abdominal palpation soft and comfortable
Feels like a little bit of sand on rectal. Yellow faeces, rectm empty

Abdominal rads: (VD and lateral)
GIT empty, moderate amount of gas ni stomach, otherwise unremarkable

Quick repeat abdo US unremarkable

Tx:
ACP 0.01mg/kg IV + gaba 300mg and diazepam 5mg in AM - slightly sedated but not much. 
IV hartmanns at 4ml/kg/hr through the day 
Metomide 1.8ml IV - disp more metoclorpamide tabs - 10mg

Recheck
sore tummy lethargic last couple of days
HISTORY
Presenting for: Henry presented for decreased water consumption and inability to drink properly, including after returning from the beach
Drinking/Urination: Not drinking water despite fresh water being provided in separate bowl, unable to drink even after beach visit

EXAM
Abdominal: Ultrasound findings show right side appearing bright white, suggestive of possible inflammation
Rectal: Rectal examination performed to assess for presence of stool

ASSESSMENT
Dehydration and inappetence - possible underlying inflammatory condition based on ultrasound findings

PLAN
Medications/Treatments:
- Opioid injection administered for pain relief, duration 8-10 hours, can return for additional dose if needed
Diet Recs:
- Exclusive diet of watered down food only at present
Additional Discussion:
- Beach access available tomorrow depending on patient response
- Monitor response to pain relief and hydration status
- Return if additional pain relief needed

Recheck
sore tummy lethargic last couple of days