C10032069 / invoice 10000

Reason: HGEHospital Time Period: 06:00-18:00History:3rd hospital period for AHDSCritical P- WBC trending down- to be rechecked todayMild elevation to ALT noted on initial bloods, resolved on ext blood yesterdayMVSC tech AUS- no evidence of obstructive process, ileus, small liver noted (may be normal, cannot exclude congenital issue eg PSS). Overnight, BG trending down, maintaining body temp, lactate creeping up, regurgitation resolved, however suspect aspiration pneumonia given TFAST findings. Subjective: QAR/D&D Objective:Temp:  36.66-37.0           MM:  pink            CRT:  <2           HR: 160            FP:  SSP             RR: 32BCS:    5/9                Wgt: 4.89   kg Pain Score (CSU): 0-1  /4CV:   no murmurs or arrhythmias noted, synchronous with pulseBPS AV 116/80 (90) RESP: Mild increase to resp effort, No coughing, no orthopnea, mild increase to lung sounds bilaterally, SPO2 ~98% RA           GIT:  comfortable on abdo palp, no splinting/tensing noted, passed very soft, brown faecesU/G: NAD Neuro: D&D M/S: Non ambulatory, comfortable on ROM of jts Integ: Bruising over most venepuncture sites- hirudoid cream appliedNo visible perianal scalding, but bottom tender when barrier creams applied Ophth: NAD LNs: Nil peripheral lymphadenopathy. INTERNAL LABORATORYPCV/TS:42/20 	Blood Gases:pH 7.350PCO2 32.3 HCO3 17.9 (L) BE -6.8 cSO2Electrolytes:Na+ 141 K     3.5 Cl   120 Glucose  6.5 Lactate 4.3 Ionised Ca 1.32 EXTERNAL LABORATORY  Lab No: 	***pending ***Sample: Interpretation:IMAGINGAFAST: 0/4 FFS TFAST: query scant pleural effusion, coalescing B lines bilaterally, shred sign, no pericardial effusion Problem List:Regurgitation with bloody fluid -> resolvedHematochezia -> improvingAnorexiaDull DemeanorTachycardiaHypothermia -> improvingMild hyperlactaemiaLymphopeniaHypoproteinemia -> improvingHemoconcentration -> improvingHypoglycemiaBilateral coalescing B-lines craniodorsallyAssessment: Treatment:1ml/kg dextrose bolus diluted 1:35% dextrose CRIMaropitant 1mg/kg slow IV q 24 hoursEsomeprazole 1mg/kg slow IV q 12 hoursOndansetron 0.41mg/kg slow IV q 8 hoursAmpicillin 30mg/kg IV q 6 hoursMetronidazole 13.07mg/kg slow IV q 12 hoursBuprenorphine 0.01mg/kg slow IV q 8 hoursMetoclopramide CRI slightly > 2mg/kg/dayEnrofloxacin 10mg/kg slow IV q 24 hoursIVFT calculated to account for medications in. 5% dehydrated, OL--> 29ml/hr (fluid cal on smartflow). NGT suctioning, emeraid reduced to 1/4 RER every 4 hours. Bottom care, barrier creamsHirudoid to bruised areas. Active warming to temp of 37- then discontinued. Plan: Diagnostic plan :Therapeutic plan :Discharge plan :Referral plan :Client Communication:Financial Update:Options Offered to Client for Ongoing Care:    Vital Signs    Weight: 4.4;