C09984252 / invoice 10000

NOTES: Reason: Castration

Nurse initials:SD
Consent form signed: Y
Resuscitation directive: Y
Pet insurance? Y  If Y have you updated the patient file?
Microchip status 
Tattoos placed?  Added to file Y/N

Preventative Health UTD Y/N

Pre sx exam  :             Heart rate :      MM :   pink        CRT :   <2s        Temp: 
Dental Grade:

Intravenous Catheter placed and IVFT initiated @5mls/kg/hr during procedure, reduced to 2ml/kg/hour post op.
Premed 0.36mL ACP/ 1.43 Methadone IM at 8:53am 
Induced with 2.5mls of Alfaxan  9mm E-T tube placed and maintained on 2% Isofluorane
Pulse ox and respiratory rate monitoring throughout procedure. Heat mat during procedure.
Refer to GA chart for complete monitoring
GA start time:
GA Finish time
Surgery Start time:
Surgery Finish time:
Anaesthetic was ###

Surgical Procedure: Routine open castration performed. Double ligated testicular vessels and ductus deferens with 2/0 PDS.  Closed s/c with 2/0 pds simple continuous, incorporating the median raphe. Closed the skin with 2/0 PDS intradermals.
Laser: done/charged YES/NO

IVFT maintained until animal in sternal recumbency
No metacam given once in sternal recumbency


TGH with meloxicam 0.1mg/kg po sid for 3 days, starting the day after surgery. R/v in 3 days. Owner to monitor for licking, incisional redness/oozing/bleeding, excessive bruising, lethargy.

Post-op sheet given: Y/N
Client called/discharge appointment made: Y/N
Post-op check rebooked: Y/N
Reminders updated: Y/N

HISTORY: NB tried to ring Linda in regards to Ted - left message for owner to ring back 

Owner tried abs with food and V+ approx 1 1/2 hours later - tried without food and no difference
Is really flat at the moment - possibly cone annoying him, tried to bite with cone on
Spot on back leg not looking good 

Plan:
Owner has metacam liquid at home from other dog and would like to trial it as concerned that Ted is quite sore and grumpy - advised can give oral liquid dose of 35kg once daily with food 
Advised that can give half antibiotic dose and if still vomiting then will change antibiotic to amoxyclav. Owner will give metacam now and cephalexin this afternoon so if vomits then knows which medication caused it.
WRMRQ: N
FLRQ: N

HISTORY: Preventative Health Questions:
Nurse initials:AO
Vaccinations Status: UTD - due soon
Worming Status/Product: UTD 
Heartworm Prevention Status/Product: 
Flea Prevention status/Product:
Travelling areas high tick prevalence? Y/N 
Microchipped? Y
Diet: Optimum puppy 

Previous treatment: cytopoint & neocourt for skin issues 
Current medications: none 

REASON: Irritated skin after groomer used different shampoo 

HISTORY:
Does lick his paws 
No V or D
O is wondering if Ted could have anti-anxiety medications for the clinic as he gets very nervous - coming in for desexing next week. 

EXAM:
BAR
MM pink, CRT <2
Dental grade   1/4 - very minor calculus build up 
Body condition score 5-6/9
HR: 80bpm Clear no murmurs 
Thoracic auscultation:Clear 
Abdo palpation:Comfortable 
LN: superficial LN's small and symmetrical 
eyes: cornea clear, no epiphora or scleral reddening 
ears: pinna not inflammed, minor waxy build up 
MSK: WNL, ambulating well in consult 
Skin: saliva staining on paws - more severe in forelimbs - no grass-seeds/Fb's between paw pads. Large hotspot on left hip, irritated hyperaemic skin surrounding it. Raised, red papules on groin that have also been causing irritation.

Assessment:
Large hot spot on top of left hip. Cleaned area with diluted chlorhex. 

Plan:
Have given 1 vial of a 40mg cytopoint and dispensed 1000mg cephalexin 1 tablet BID for 7 days to clear pyoderma and staph infection. 
Ted is to wear E collar to reduce licking of the pyoderma - was attempting to do this lots in consult. 
O is worried about upcoming storm and the vet visit next week as Ted can be quite reactive. Dispensed trazadone to give the night prior and the morning off vet visit to help with this. Recheck skin and response to trazadone at time of desexing. 

Owner consent to treatment? Y
Owner consent to cost? Y
Repeat Prescriptions? N Simple noted updated?
Reminders updated: Y
Quote for procedure & deposit discussed? Y
Rebooked: Y
WRMRQ: N
FLRQ: N
WEIGHT: 35.32