C09975801 / invoice 10000

NOTES: 24 Nov 2025 01:58:43 pm YHL

Presented for: annual vacc
History: settled in well at home. EDDU normally, good appetite, V-D-. no concerns to note
Diet: dry. 
Vaccination status: DUE
Worming (ectoparasite, intestinal worming, HW): UTD milbemax
Medication given: NIL 

Physical Examination
BCS 5/9 & Demeanour BAR
Cardio/Respiratory: HR  190 bpm, RR  24 bpm. MM pink,  CRT <2 seconds
Thoracic auscultation: Clear bronchiovesicular sound, no heart murmur
Eyes: Clear, 3rd eyelid NAD
Ears: NAD, clean
Integument system: soft coat, free of ectoparasite, NAD
Lymph node: submandibular WNL, pre-scapular WNL, popliteal WNL
Dental score: 1/4, no gingivitis
Abdominal palpation: soft, no pain elicits on palpation
Musculoskeletal examination: ambulation normal

assessment:
- fit for vacc
 
Diagnostic plan/treatment:
- given C3 SC

Client communication: 
- cont annual vacc and preventative
- O mentioned P has abnormal heart beat while sleeping. told O to take a video and send it to us if concerned

HISTORY: 01 Oct 2025 02:54:25 pm KG

Weight: 2.85kg 

One week post spey
O reports has been doing well, eddu as normal, no V or D. Inside cat. O has a vest over incision site to stop Tilly licking area. 

Bright & Responsive, pink moist mm, Capillary refill time 1-2sec.
Abodminal palpation comfortable
Temp 38,4
HR 160bpm, Respiratory Rate 24brpm with clear lung sounds 
Incision site healing noicely, mild puckering at proximal and distal edges, no necrosis or discharge. Mild inflammation under skin in area, no pain - likely suture reaction, fibrosis vs other. No evidence of infection however advised O to keep an eye on the site nd represent asap if inflammation does not resolve or if Tilly becomes lethargic, inappetent etc. 

Recheck in a week or sooner if concerned.

SUBJECTIVE: Presented for spey
Consented to pre-GA bloods
Consent form signed, fasted 12 hours
OBJECTIVE: T:37.5 Capillary refill time 1-2s mm pink and moist
HR:196bpm RR: panting

demeanor: Bright & Responsive. smoochy
eyes/ears: No abnormalities detected
oral: DS 0.5, staining present
LN: submandibular, prescapular and popliteal WNL
cardio/resp: no murmurs, no arrhythmias, normal BV sounds bilat
abdo: soft, comfortable
ASSESMENT: fit for GA 
pre-GA bloods unremarkable (originally read anaemic but suspect blood tube clotted, re-run and NAD)
PLAN: Pre-medicated with 0.4mg.kg methadone (0.1ml) and 0.02mg/kg ACP (0.02ml). 22G catheter placed R cephalic. Induced with 0.9ml alfaxan slow IV to effect. Intubated with size 3.5 cuffed ET tube (although cuff not inflated) and maintained on oxygen and isoflurane
Stable anaesthetic
Routine OHE performed, ovarian pedicles and uterine stump double ligated with 3/0 monoplus. Linear alba closed with 3/0 monoplus simple continuous, subcut layer closed with 3/0 monoplus simple continuous, intradermals used for skin layer
Meloxicam 0.2mg/kg (0.1ml) SC post op.