C09987017 / invoice 10000

Reason: Eaten Rat PoisonHistory:BAR, EDDU normal, no VCDS Brought in for ingestion of rat bait powderTime period of ingestion: half an agoConcurrent medications: NoneAny other health concerns: NoneExamine:BARBCS  2/5TPR WNLsIntact gag & normal mentationChest NADAbdo palp NADIntegument NADNormothermicAssessment:Rat bait toxicityTreatment:Redivom 0.46 mls SC Vomit: PInk raitbait seenPlan:May still vomit in the next hour or two, if continues severely contact clinicTake home medications: NoneCheck coags in 2-3 days (PT APPT ONLY)    Vital Signs    Weight: 4.6;       MMColour: pink moist;       Temperature: 39.2;       HeartRate: 180;       CRT: 1sec;       

HISTORYClient presenting Patient:  chrisPresenting complaint: vaccination and healthHow long as problem been present: n/aAny other concerns:noneEDDU: normalDiet: dry and wet food Current medications:noneMajor medical history/ongoing condition: noneVaccination (When and what): dueWorming & External parasite prevention (When and what): monthly . Not sure of productPHYSICAL EXAMINATIONGeneral demeanor: bar, shyEyes:NADEars: NADOral: mild tartarThoracic + Cardiac auscultation: NAD, normal sounds, pattern and effortAbdominal palpation: NAD, normal palpation with organs easily identifiableIntegument: NAD, normal skin and smooth coatPeripheral lymphnodes: NADMasculoskeletal + Gait: NADNeurological: Normal mentation, no full work up.Urogenital: NAD, DesexedAssessment:1. Mild tartar on teethTreatment:C4 s/c dorsal midlinePlan:1. Home dental care2. C4 in 12 months    Vital Signs    Weight: 4.5;       MMColour: pink;       Temperature: 37.8;       HeartRate: 124;       BodyScore: 5/9;       DentalGrade: 1/4;       RespirationRate: sniffing;       CRT: <2sec;       

Reason Spay History: Hx and PE by BAR, eddu normal, no vcds.Fasted overnight, no medications given. Examine: Oral exam NAD, mm pink and moist, Decid dentition : yes , extracted todayChest and heart NAD, Abdo palp NADNo hernia present No signs of heatNo hind dew claws Assessment:Fit for sxTreatment: Premed: 0.36 mls MAA SC IV catheterisation, Hartmanns fluid therapy commenced at maintenance and then surgical rates. Induction:      3 ml alfaxan/propofol slow  IVMaintenance isofluorane on  rebreathing circuit with ET tube size     .   Ventral abd clipped and surgically preparedRoutine mid line spay with    3/0 PDS double ligation of ovarian pedicles and uterine stump.   -3/0 PDS closure simple continuous of abdominal wall, subcutaneous tissue and intradermal sutures. No nylon skin sutures. - Two maxilla Deciduous canines extracted and the rest of the teeth were easy removalsAnaesthetic Quality: Good, no complications. Post Op medications:Meloxicam  0.14mls SC Melxoicam oral  0.24 ml  PO SID x 3 days Plan:Routine nurse discharge, home with desexing after-care sheet.  Free recheck in next 2 weeks if any concerns.KM: 1:40pm - 0.2ml Atropine given slow IV as per DPR for Hypersalivation    Vital Signs    Weight: 3.6;       MMColour: pink;       HeartRate: 124;       BodyScore: 5/9;       CRT: <2sec;