C10032694 / invoice 10000

Reason: REFERRAL - Fluids And Repeat BloodsHospitalisation time period: 1500 - 1900:HISTORY:Night 2 hospitalisation for sultana ingestion Referral from RV - emesis was performed, AC administered and stayed in clinic on IVFT during the day. Urea was slightly elevated (at 24h mark) on bloodsSee preivous history for full details EXAMINATION: BARHR 145, RR sniff, Mm pink/moist, CRT <2s,Weight = 8.7kgBCS 4/9Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronous Respiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal discharge Neurological: neurologically no significant findings, no cranial nerve or proprioceptive deficits/gait Musculoskeletal: ambulating normally, no palpable neck, spine, limb or joint pain Gastrointestinal: - Oral: normal, no mouth pain, dental score (1-4): - Abdominal: no detectable pain on abdominal palpation, normal gut sounds - Rectal: no detectable abnormalities, faeces: Urinary: NSFReproductive (incl ext genitalia): NSFIntegument/Ears: NSFLymph Nodes: peripheral lymph nodes normal Eyes: NSFDIAGNOSTICS: - Creatinine = 158 (44 - 159 µmol/L) - Urea = 7.7 (2.5 - 9.6 mmol/L) - ALT = 243 (10 - 125 U/L) H PROBLEM LIST: Sultana ingestion Elevated Urea - resolved ASSESSMENT: Zaza remains CVS stable. Eating well in clinic. Repeat bloods @ 48h mark - urea normalied, creatinine/SDMA NAD TREATMENT: 1/ LRS 20ml/hrPLAN: Discharge at 7pm tonight CLIENT COMMUNICATION:--- 14/03/2026 5:36:21 PM ADC:Updated owner post bloods -advised everything looking good. Given still eating well, no vomits/diarrhoea and bloods NAD at 48h mark - OK for d/c home Discharge at 7pm  tonight    Vital Signs    

Reason: REFERRAL - Fluids And Repeat BloodsHOSP PERIOD: 2300-0700VITALS:- HR: 128- RR: 32- Temp: -- MM: Pink - CRT: 1.5 seconds- Mentation: BAR- BCS (1-9): 4/9EXAMINATION:- Cardiovascular: normal rate and rhythm. Pulses strong and synchronous.- Respiratory: NAD - no nasal discharge noted, normal respiratory rate and effort, bronchovesicular sounds are normal to all fields, URT noise- Neurological: NAD - normal mentation, no notable CN or CP deficits, full exam not performed- Gastrointestinal:   - Oral: Oral mucosa appears normal, no lesions noted.  - Abdominal: Normal on abdominal palpation, no obvious masses noted, comfortable- Musculoskeletal: NAD - no evidence of lameness or pain. Full MSK exam not performed.- Ears: NAD - pinnae normal- Eyes: Eyes clear with no obvious discharge or changes associated- Lymph Nodes: NAD - peripheral LNs normal in size, no firm or painful LNs identified- Urogenital: NAD- Integument: NAD - coat normal, no obvious masses or other lesions; full exam not performedDIAGNOSTICS: NilPROBLEM LIST:Grape ingestionASSESSMENT:CV stable, no clinical signs have developed PLAN:Repeat renals at 5pm - sup care until then TREATMENT:IVFT LRS    Vital Signs    

Reason: REFERRAL - Fluids And Repeat BloodsHOSP PERIOD: 2300-0700VITALS:- HR: 100- RR: Sniffing- Temp: - 37.4- MM: Pink - CRT: 1.5 seconds- Mentation: BAR- BCS (1-9): 4/9EXAMINATION:- Cardiovascular: normal rate and rhythm. Pulses strong and synchronous.- Respiratory: NAD - no nasal discharge noted, normal respiratory rate and effort, bronchovesicular sounds are normal to all fields, URT noise- Neurological: NAD - normal mentation, no notable CN or CP deficits, full exam not performed- Gastrointestinal:   - Oral: Oral mucosa appears normal, no lesions noted.  - Abdominal: Normal on abdominal palpation, no obvious masses noted, comfortable- Musculoskeletal: NAD - no evidence of lameness or pain. Full MSK exam not performed.- Ears: NAD - pinnae normal- Eyes: Eyes clear with no obvious discharge or changes associated- Lymph Nodes: NAD - peripheral LNs normal in size, no firm or painful LNs identified- Urogenital: NAD- Integument: NAD - coat normal, no obvious masses or other lesions; full exam not performedDIAGNOSTICS:    Vital Signs