C09984370 / invoice 10000

VL: AGHistory: went outside at christmas Eve and sore back leg since then, EDDU normally, no vomitting, no diarrhoeaOwner concerns: sore back legCurrent Preventatives/Vaccinations:Physical Exam:Behaviour: BARCardioresp: not assessedTemperature: 38.5 - not that far in so could be higherSkin and coat: not assessedEyes and Ears: not assessedMusculoskeletal: sore hind R/leg, a bite wound on the lateral R hock with cellulitis distal to this woundAbdominal: not assessedGenitourinary: not assessedBCS:Dental score: Diet: a sachet of wet food and dry foodProblem List: bite woundDifferential Diagnosis: cat fight woundRecommendations Ongoing/Recheck:- Put her on juroclav 50mg bid q5days and short course of pain relief

Nurse: AGPreop exam: MM/CRT: Pink/1s HR: 146 RR: 22 Behaviour:lovelyPremed: 0.12ml methadone + 0.12 ml medetomidine + 0.12 midazolam IMIV catheter placed and commenced on IV fluids Induction: 0.1 ml aflaxanIntubated with 3 mm cuffed ET tube Maintenance: iso/o2 Sx:Drain abscessRecovery: smoothPlan: Home with 3 days oral meloxicam 0.35 ml SID with food POC 3 days aftercare information given.

History:Owner concerns:            Discharging wound on back.  Not eating as much as normal.  Drinking.Current Preventatives/Vaccinations:Physical Exam:Behaviour:                 Quiet.Cardioresp:                HR 180 bpm.  Normal sounds.Temperature:              Tried to take temp.Skin and coat:            Wound on middle of back.Eyes and Ears:           Clean and clear.Musculoskeletal:         Moving well enough to avoid having temp taken.Abdominal:                 Comfortable on palp.Genitourinary:             Not checked.BCS:                           4/9Dental score:               Not taken.Diet:                             Whiskas wet and dry.Problem List:               Wound on back.Differential Diagnosis:  AbscessDiagnostics:                Medications:                 Meloxicam inj.Recommendations Ongoing/Recheck:   Sx tomorrow for clip, clean and debridement.