C10032847 / invoice 10000

CLIENT DISCHARGE NOTESPRESENTING CONCERNS:Concern for eating a pencil on Thursday. Today lethargic and eating less enthusiastically. PROBLEM LIST FROM PHYSICAL EXAMINATION AND HISTORY:Fever (39.5), tense in abdomenASSESSMENT:No pencil found in stomach or intestinal tract. No free fluid seen on ultrasound in abdomen. DIAGNOSTICS/MANAGEMENT:Radiographs - No evidence of pencil in stomach or intestinal tract.Pain reliefPLAN:Discharge home for continued monitoring and pain relief. Medications for Administration at Home:Panadol (Paracetamol) 500mg: Give 1/4 (0.25) of a tab 2-3 times daily for pain relief and to reduce fever. Give first dose this evening.-Over the counter medication. SPECIFIC HOME CARE INSTRUCTIONS:The Animal Emergency Service advises a reassessment with your regular vet within 48 hours to monitor your pets progress.  If your pet's condition deteriorates or they become flat or lethargic, go off their food and water, develop vomiting or diarrhoea or if you have any concerns please contact the Animal Emergency Service or your primary vet immediately.Thank you for trusting the Animal Emergency Service with the care of Ivory.    Vital Signs    

Reason: sus pencil ingesiton thursday, painful today NQR-WHISTORY:Current meds:Prophylaxis:Pre-existing conditions:Access to toxins eg. Rodenticide:TRIAGE:HR:RR:Temp:Mm: Crt:Mentation:Pain Scale (0-4):Hydration status (%):EXAMINATION:Body Condition Score: Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- 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 normalEyes: NSFPROBLEM LIST:DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:DIAGNOSTIC/MANAGEMENT PLAN:DIAGNOSTICS:ASSESSMENT:TREATMENT:PLAN:CLIENT COMMUNICATION:------------------------------------------------------------------------CLIENT DISCHARGE NOTESPRESENTING CONCERNS:PROBLEM LIST FROM PHYSICAL EXAMINATION AND HISTORY:ASSESSMENT:PLAN/DISCUSSION:TREATMENTS ADMINISTERED:Medications for Administration at Home:SPECIFIC HOME CARE INSTRUCTIONS:The Animal Emergency Service advises a reassessment with your regular vet within 48 hours to monitor your pets progress.  If your pet's condition deteriorates or they become flat or lethargic, go off their food and water, develop vomiting or diarrhoea or if you have any concerns please contact the Animal Emergency Service or your regular vet immediately.If your pet is going home and has a pressure wrap over where an IV catheter was placed please remove it within 20 minutes of leaving the hospital.Thank you for trusting the Animal Emergency Service with the care of your pet.Radiology : Digital radiography was performed.Thoracic: Extra thoracic structures: no significant abnormalities, skeletal and subcutaneous structures normal* Diaphragm: Intact*Pleural space: No air or fluid*Large airways: Normal, normal dorsal tracheal membrane*Pulmonary: No pathological pulmonary pattern present*Cardiac: Normal size and outline*Oesophageal:  no air or foreign body present* Abdominal:Extra-abdominal structures: no significant abnormalities Serosal detail: good*Liver/spleen: normal size and outline*GIT: No obvious radiopaque foreign body, or intestinal gas dilation (< height of L2 in dogs, L4 in cats)Kidneys:  - Left, normal size and outline*- Right, normal, but cannot visualise completely (due to the liver)*- No obvious renoliths*Bladder/Prostate: bladder present, no obvious radiopaque uroliths* Xray Interpretation:    Vital Signs