C09991490 / invoice 10000

HISTORY: History

Right Hind Leg paw stitch up on paw pad, est 800aud (check estiamte on file and bill accordingly) 

Clinical examination

Pre-Anaesthetic Bloods: Declined by Client

Fluid Therapy:  Declined by Client
22 gauge catheter placed R cephalic v. 

Premed exam: NAD
Methadone 0.88ml IM and ACP 0.59ml IM, Administered: 1:10pm 

Induction propofol 17.7ml slowly to effect R cephalic v. 

ET tube size: 11mm cuffed

Shaved and prep for surgery GA maintenance & Surgery Oxygen and 2/3% isoflurane 
Oxygen Start time: 1:55pm 
Oxygen Finish time: 2:30pm 
Total anaesthetic time: mins 

Wound site clipped, prepared with surgical chlorhex dilution scrub and preped for surgery. Wound debrided with a size 15 blade, flushed with saline, and wound margins refreshed/resected. A drain was/was not placed (penrose/jackson pratt), the muscle layer if affected closed with 2-0 PDO suture, and subcutaneous tissue closed with 2-0 PDO in a simple continuous pattern. The skin was closed with 2-0 Nylon in a cruciate pattern.  

Post op: Uneventful recovery 

Analgesia: 1.2ml meloxicam SC @ 2:35pm
Antibiotics: amoxyclav oral
Discharge instructions provided 
Drain placed: 

IF CAT - Discussed FIV vac and testing: 

PLAN-
SR 14 days
WEIGHT: 29.5

HISTORY: Presenting issues:
O noticed a cut on his foot after walk yesterday, he started bleeding this morning
Not on any medication

Examination: 
Demeanour- BAR, super anxious, limited exam
BCS (1-9) -  4/9               
Eyes- no abnormality detected (NAD)
Teeth/mouth-       Teeth Grade (1-4)  0/4     Dental Required N            MM: pink        CRT: <2seconds
Heart rate-    unable to auscultate
Skin- an abrasion with skin sloughed off just proximal to RH metatarsal paw pad                    

Differenital diagnosis and client discussion: 
> Ddx: self trauma injury
> Discussed treatment options - bandaging the leg under sedation vs stitch up 
O elected stitch up quoted $800

Plan:
> Stitch up tomorrow
WEIGHT: 29.50