C09978541 / invoice 10000

Reason: Poss Abcess On HindConsultation Time: 2230History: - Presented for assessment of a wound on his bottom on the right side- The owner first noticed it yesterday and observed some bleeding after cleaning the area. Today, a "gunky" discharge was noted from the lesion. There is associated scooting and licking of the area, which has increased in frequency today- No prior history of similar issues- No vomiting or diarrhoea reported- Has had normal formed faeces as per O- Diet: royal canin toy poodle dry food - Nil hx major health problems- Nil current prescription medications - UTD with vaccinations and prevention- Nil access to toxins, medications etc Subjective:  BAR, distressed/hyper-aroused, FAS 3-4/5Objective:  Temp 39.4  MM  pink, moist   CRT <2s   HR  200   FP SSBCS:   5/9                       Wt:  3.4 kgPain Score (CSU):   3/4CV:  nil murmur/arrhythmia, femoral pulses readily bilaterally, hydration parameters WNL. RESP:  Lung sounds clear. RR pant excessively. RE normal GIT:   Abdomen tense but non painful, NOAD palpable, DRE unable to be performed as not tolerated by P, right anal gland full with associated ruptured abscess> expressed small amount thick, brown material; small open wound with purulent-caseous to bloody discharge, extremely painful and P would not tolerate so had to abort   U/G:  NAD, small soft bladder palpated Neuro:  Mentation alert, very distressed, nil CP deficits, full neuro exam deferred M/S: ambulatory x 4, full msk exam not performed Integ: open wound R side of anus with large amount of bruising, erythema and swelling - purulent, caseous, bloody discharge Ophth:  Pupils symmetrical, appears visual, mydriatic pupils bilat LNs: Nil peripheral lymphadenopathyProblem List:Ruptured anal gland abscess PainSevere anxiety Assessment: Injuries consistent with ruptured anal gland abscess, cannot rule out penetrating injury > risk of wound breakdown/deterioration, risk of infection etcOptions Offered to Client:Discussed with O's admit for full sedation +/- GA for anal gland abscess drain and wound care etc as P not tolerating without sedation vs outpatient management following attempt at wound clip and clean after analgesia and to go home with medications and to visit rDVM for further intervention if abscess does not resolve now it has ruptured. O elect outpatient management. Discussed risks associated with NSAID use - O understanding and accepting. Treatment:Gabapentin 50mg PO in consult Methadone 0.2mg/kg SQWounds clipped and flushed with isotonic sterile saline. Meloxicam 1.5mg/ml oral suspension 3.4kg dose SID for 3 daysAmoxyclav 50mg PO BID for 7 daysNeocort 50g TOP BID Plan:Confine indoorsMonitorE-collar at all timesRevisit at reg vet in AM if not eating, drinking or no toileting for further investigation, if the wound looks larger or worse in any way, or if he seems to be uncomfortable, otherwise at reg vet for revisit in 2-3 days    Vital Signs    Weight: 3.4;       

Reason: VomitingConsultation Time:History: Adopted last week,new dog owners. They have been feeding the supermarket puppy wet food that the breeder recommended. Biscuit vomited 3 days ago after a treat so no more treats. Biscuit vomited again today. Eats very quickly and then vomits. As vitals all ok, recommended 3 days or chicken and rice fed in small amounts q4.No vet visit needed.Subjective: Objective: Temp       39     MM     pink/dry         CRT     1        HR      132       FP goodBCS:   /9                       Wt:   kgPain Score (CSU):   /4CV:  NAD       RESP:   NAD      24     RRGIT:   NAD - no pain on palpU/G:  NADNeuro:  NADM/S:  NADInteg:  NADOphth:  NADLNs: NADSF    Vital Signs