SOAP Note (Veterinary Hospitalisation)

Reason: Bella, a 5-year-old Labrador Retriever, was referred for evaluation due to persistent vomiting and lethargy over the past 48 hours. The owner reported that Bella had ingested a foreign object during a walk. Time: 14:30 Objective: - Bodyweight: 30 kg - Demeanour: Alert but slightly lethargic - TPR: - HR: 110 beats per minute - RR: 24 per minute - MM Colour: Pink - CRT: 1.5 seconds - Temp: 38.5°C - Blood pressure: 120/80 mmHg - CVS: No significant findings on auscultation. Pulses normal - Resp: No significant findings on auscultation. Normal respiratory rate and character at rest. - Abdo/ALI: Mild discomfort on abdominal palpation, possible foreign body palpable - Catheter Site: No significant findings. Catheter patent - Hydration: Mild dehydration noted Diagnostics: - Abdominal X-ray: Foreign object detected in the stomach - Bloodwork: Elevated white blood cell count Assessment: Bella is experiencing gastrointestinal distress likely due to the ingestion of a foreign object. The presence of the object in the stomach is causing vomiting and mild dehydration. Treatment: - Administered IV fluids to address dehydration - Initiated antiemetic therapy - Scheduled for endoscopic retrieval of the foreign object - Refer to flowsheet for full treatment plan Plan: - Continue hospitalisation until fit for discharge - Monitor hydration status and adjust fluid therapy as needed - Re-evaluate post-endoscopy for any complications