C09986697 / invoice 10000

Dental with extraction due to tramatic injury

Gave oral meloxicam 6:30am yesterday
Dog Dental

Pre Dental PE:
TPR:
PreGA bloods: N/A

Aneasthesia:
Premedication: Medetomidine  (0.01mg/kg) and Methone (0.3mg/kg) IV
Induction: Alfaxalone 2mg/kg via intravenous catheter in the cephalic vein.
Maintenance: Oxygen and isoflurane via an endotracheal tube.

Procedure:
Routine ultrasonic scale and polish.
Plaque/tartar - grade (1)
Ginigivitis - grade (1)
Periodontal disease - grade (0)

Extractions (103) - cracked incisor and exposure of root. gum left open

Abnormal - 309 (Minor slab fracture), 311 (discolouration)

Medication:
Metacam TGH (already got some at home)

Plan:
1. Oral hygeine 
2. NSAIDS at home
3.POC 3-10 days 

cracked incisor?

Hx:
Yelped when o touched the face. On checking, O relised that one of Duke's upper inscisors is broken.
O gave oral meloxicam at home earlier

Examination Findings:- 
Hydration: normal
General demeanour: QAR
Temperature: N/T
Cardiovascular: HR- 120, nil murmur auscultated
Respiratory: clear lung sounds and normal effort
Abdomen: soft on palpation
Eyes: nil discharge
Ears: nsf
Oral exam: mm pink and moist CRT 1-2 sec. Dental Score(1-4): 2 - fructure 203
Integument:  nsf - no scaling and erythema
Urogenital: nsf
Peripheral LNs: wnl
Musculoskeletal: wnl, full M/S exam not performed
Gait: able to stand without assistance, walks normally
Neurological: alert 
Rectal exam: Nil

Assessment: 
Broekn 203.
But also painful to touch righ upper face.

Plan:
Bloods
Bookd in for GA, dental rads and extraction.
Check for any jaw lesions/fractures

Rx:
Nil
Estimate on file

AHC and vax

H - Been going well. O reported that had a good response to alprazalam with storms. Seems less fearful in general after a number of storm fear prevention.
Dose is 1/2 a tablet = 1mg lasts 4-5 hours

O - BAR, mm pink well hydrated, abdomenal palpation NAD, Joints full ROM, Temp 38.7, HR 120, rr 30, grade 0 dental disease

A - in good health

P - Given SR12 injection, C5 vaccination. 
Dispensed alprazalam.
Intestinal wormer dispensed