C09974419 / invoice 10000

02/03/2026 COHAT Cleaning & Assessment Stage 1
History: 
- here for GS removal and possible COHAT stage 1 
- please review Hx, previous been on medical treatment for GS 

Current Medications=
Lab Results: 

Anaesthesia Risk (grade 1-5) = 1/5
Anaesthesia: protocol achieved good sedation, good dog to place IVC without premed
Premedication - methadone 0.3mg/kg, medetomidine 0.01mg/kg 
Induction - alfaxan 0.4 mL 
Maintenance - ISO/O2 

Dental Radiology:
- all teeth performed radiograph
- no periodontal bone loss detected 
- n missing teeth  

Dental Assessment/Oral Examination:
- mild plaque on both upper carnassial and canines 
- no pocketing >3 mm
- no furcation/ mobile teeth

Treatment: 
- all teeth been scaled and polished  

Assessment:
- general swelling on dorsal aspect of RF paw (from P3 extending to P4)  
- a drain tract observed on P3 digit, mild purulent discharge expressed 
- 0.1 mL lignocaine injected SC proximal to P3 digit
- extended drain tract with size 15 scalpel and infilled with 0.3 mL lignocaine
- ONE GS retrieved by using alligator forceps, no other F.B found
- wound been flushed with vigorous amount of diluted chlorhexidine
- light bandage put on

Plan:
Stage 2 required NO ...
- r/v for bandage removal in 3 days
- restarted amoxiclav and metacam 

R / R / R:

02/03/2026 Reason: grass seed 
HISTORY:  
10 days ago start licking paw ,O went to paws at prospect where Abs and NSAIDS were dispensed - pending history
 O found grass seed on ventral surface - still licking 
 
N = No Abnormalities Detected 
Behaviour= BAR 
Current Meds= abs was last given yesterday and NSAIDS finished 2 days ago  
Diet History=  same 
Worming =  uk
Heartworm =  as above 
Flea Control = as above 
Microchip Scanned =  

EXAMINATION: 
Gen App: 
HR/CVasc: 90
RR/Ausc: clear 
Temp: not taken 
Dental Stage:  1
MM / CRT: p/1
BCS (/9): 5
Ideal Weight:  
Pain Score: paw
Eyes:   n
Ears:  n 
Oral C:   n
H/lymph: n n
Abdo/GIT:  
Skin:  right paw draining sinus oozing pus - possible grass seed 
M/S:   
U/G:  
Neuro:  
Wellness bloods:  

ASSESSMENT:  possible grass seed - been there for long time, warned O about migration 

TREATMENT: 
admit for explore under GA 

PLAN: