C09974042 / invoice 10000

Appointment Notes: stitch upPertinent history:wound behind R ear from grooming mishapMorning physical examination:HR:     140           RR:    PANTING        MM:   pink           CRT:    <2s      Temp: 38.8Any other abnormal findings:** examination of throat upon entubation showed a hypoplastic epiglottis and suspected hypoplastic trachea. Opening of larynx is smaller than it should be and only allowed a 5.5mm ET tube to be placedProcedure (what is patient in for):stitch upMedications currently on and time last given: nonePre-anaesthetic blood results:stress leukogramALT 190 (0-120)- prev 400Diagnostic results:ear cytology- debris onlyPremedication:dexdomitor 0.45 ml Methadone (10mg/ml) 1.0 ml      Fluid type and rate:Hartmanns ml/hrInduction:Alfaxan 3.0ml IV to effect (10mg/ml)ETT size:        5.5mm                            Location of catheter: R cephalicIsoflurane rate / oxygen rate:2%/ 1.0L per minSurgical history:flushed wound thoroughly and used dry swabs to debride. trimmed the wound edges until bleeding. Closed SC layer 3/0 pds simple continuous patternPre/Peri/Post operative medications given and time: meloxicam 1.2ml SC @ 2.05pmPain management plan:meloxicam to start after 2.30 pm tomorrowHome care / discharge instructions:small meal for dinnerstart clav tablets tonight with dinnerremove dressing in 3-5 dayskeep e collar on for 10 days, no swimming for 14 daysmust have thoracic xrays before any future GA proceduresRevisit date: 5 dayss/o 10-14 days    Vital Signs