C09986969 / invoice 10000

Lump removal LaboratoryHistopath declinedTreatment:Pre-med:  0.04ml ACP  0.48ml methone  Induction: 4.25 ml alfaxan IV some s/c intially as catheter dispalced and needing replacing.  Maintenance: isoflurane 1.75%Peri-operative intravenous fluids: Hartmanns 16ml/hr before and after surgery.  24ml/hr during surgery Recovery: uneventful Nurse: nt LUMP REMOVAL:Lump description: (position, size, shape, etc)Lump removed with  mm margins and 1 fascial plane. Flush with saline. Bupivicaine splash or injected block. Wound closed with 3-0 PDS continuous for s/c and 2/0 polypropylene for skin.Oral meloxicam 8kg once daily for 5 days Gabapentin 100mg BID until finished Post op:Complications:Elizabethan collar 15cm Plan:s/o 10 days    Vital Signs    Weight: 8.5;       MMColour: pink;       Temperature: 39.7;       HeartRate: 220;       RespirationRate: 100;       CRT: >2;       

Extra visit    Vital Signs    

Reason: Recheck Lump - Plan For Removal - GTHistory:  Otherwise BAR, EDDU OK.Diet: RC Maine Coon dry Environment: indoors and does go out for an hour in the morning.Has had a wormer in past 6 months.Current Medications: noneExamine: Mentation: QARBCS:  7/9MMCol: pinkCRT: <2Oral cavity: teeth  2/4Eyes: NADEars: NADLN: NADHR: 160 HM 1/6Pulse: NADRR: 40Chest sounds: normal bv soundsAbdominal Palpation: NAD, large bladder and firm stool present in colonT: 38.8CIntegument: matts under tummy, ulcerated L rump 3cm x 3.5cm plaque intradermal type leison. O declined FNA.Musculo-skeletal: NADRectal palpation: NAOther:Differential Diagnosis:Benign vs malignant mass lesionPlan: booked for sx, o agreed to PAS, opted no cytology or histopath as she would not pursue regardless and does not want large margin removal as wishes wound to be sutured closed. NM    Vital Signs    Weight: 8.64;