C09976150 / invoice 10000

Reason: Swollen Face - Allergic ReactionAppointment Notes: Overdue remindersPresenting problem: Acute facial swelling.History:- Presented for swollen lip noted by O this evening.- Px had a general anaesthetic today at the rDVM for biopsy of an unknown mass on the right cd. thigh.- History of D++ for the last few days, suspected to be secondary to Meloxicam. O stopped Meloxicam on Saturday.- Px has not eaten today post-anaesthetic yet.- Known history of a very low-grade heart murmur.- Was due to be started on Protexin or Pro-kolin at home.Current medications: nilVax: Not mentionedAllergies: nilExamination findings:- Wt: 1.96 kg- Demeanour: QAR- Temp: 37.4°C (axillary)- Cardiovascular: HR 120 bpm, no murmur or arrhythmia, FP synchronous & adequate.- Respiratory: RR 40 breaths per minute, normal effort, rate, lungs clear, no cough/sneeze witnessed.- Abdomen: soft & comfortable abdomen- Peripheral LNs: no enlargement- Eyes/Ears: clear, no discharge- Integument: Swelling of the upper lip noted.- Oral: mm pink, CRT 1 second.- Musculoskeletal: normal rom- Gait: ambulatory in all limbs- Neurological: normal mentation, full neuro exam not performed- Urogenital: clear- Rectal exam: Not performed, Px would not tolerate.Problem list:- Acute facial (lip) swelling: DDx includes hypersensitivity reaction (allergen, medication reaction, histamine release from mass sampling).- D++: DDx includes medication side effect (Meloxicam).- Inappetence: DDx includes post-anaesthetic effect.- Right cd. thigh mass: Under investigation by rDVM.- Low-grade heart murmur: Incidental finding.Assessment:Suspected hypersensitivity reaction.Treatment:chlorpheniramine 0.5 mg/kg (0.1 ml) IM @ 11:20 PM, 03/03/2026no steroid given recent NSAID administrationPlan:- chlorpheniramine 1/4 x 4mg PO q8-12hr if itchiness or swelling persists, start in the morning.- O to revisit here or rDVM if there is difficulty breathing, weakness, collapse, or V++.Client communication:Discussed with O the suspicion of a hypersensitivity reaction. Explained potential causes including an allergic reaction to an unknown allergen, a reaction to medications, or histamine release (degranulation) from the mass biopsy. Discussed treatment with chlorpheniramine, which O consented to. Advised on the plan for home care with chlorphenamine and clear signs for re-presentation.Hx sent to rDVM: --- 03/03/2026 05:01:52 HH:    Vital Signs    Weight: 1.9;       Temperature: 37.4;