C09985946 / invoice 10000

Reason: choc ingestion

History: 
between 9-10am, came home around 10:15am and noticed a few milk choc wrappings 
otherwise doing ok at home

Examine:
Mentation: BAR              BCS: 5/9
HR: 130 bpm no arrythmia
RR: chest clear 
Temp: not attempted           MM/CRT: p m <2s 

Assessment/Treatment: 
induced emesis - gave apomorphine IV
able to see large quantities of brown/choc
vomit until only bile 

gave maropitant 1mg/kg sc
dispensed activated charcoal 3ml/kg po to give at home

Plan: 
monitor for tremours, seizure etc, rv asap if concerns

Reason: PSC 

History: had buster collar on until now
doing well at home 

Examine:
Mentation: BAR 
very mild seroma along incision line otherwise surgical site healed well, clean and dry, no discomfort on palpation

Assessment/Treatment/Plan:  
can take buster collar off
slowly inc exercise level
rv if concerns

REASON FOR ADMIT/ PROCEDURE: Spey with PAS, NO tattoos.

VOMITING: Nil
DIARRHOEA: Nil

FASTED: Yes, since 9:30pm
VACCINATION: UTD
HEARTWORM PREVENTION: UTD

ALLERGIES: None known
MEDICATION: Nil

CONSENT TO SOCIAL MEDIA: YES/NO: Not answered

TEMP: 39.1
HR: 160 NAD
RR: 30 clear
MM: Pk
CRT: 2 sec
DEMEANOR: BAR

PAS: 
mild electrolytes changes
low patelets - blood smear checked, clotting adequately
hyperglycaemia - suspect stress related

Pre-medication: acepromazine (0.04mg/kg IM) and methadone (0.4mg/kg IM)
Induction: Alfaxalone 
IV catheter: R cephalic                     Fluid therapy (mL/hr): surgery 15 (IVFT started pre-op file waiting for blood test result - total IV 17ml) 
ET size tube: 5.5

Surgery: Routine midline spey

lignocaine line block applied 

The pedicles and the uterus were ligated using 3/0 PDM.
Linea alba and subcutis were closed using 3/0 PDM.
Intradermal sutures were applied using 3/0 PDM.

Recovery: smooth recovery

Peri-op medications: meloxicam (0.1mg/kg sc)
Home medications: meloxicam (0.1mg/kg sid) starting tomorrow

Plan: 
PSC if concerns