C09992253 / invoice 10000

Reason Anal glands 
Has been licking rear end for a few days. Is visibly sore. O says he has firm and soft stools. Has been passing more stools recently.
Elderly owner with elderly dog in aged care- brought in with daughter as O has slowed down a lot. 
Does get multiple things to eat + human scraps.  Is not on any pain medication as O cant get down here so needs help from her children. 

PE; 
Eyes bilaterally nuclear sclerosis 
ears bilaterally nad mm pigmented moist 
msk; marked OA/DJD changes all limps with inward rotation of carpus. 
skin multiple warts all over. 
Anal gland : both extremely full unable to express without sedation. L side likely to abscessate. 

Client comms: 
needs sedation and flush. ASA risk high given age and comorbidities and unsure of underlying issues. Discussed long term pain relief for OA/DJD 
diet can be discussed but likely will have compliance issue - so just keeping him comfortable. 
QOL discussion would need to be had shortly if NSAIDs dont provide comfort 

MB:
Tx: 0.09ml butorphanol + 0.09ml medetomidine IM, good sedation
Still uncomfortable when palpating AGs therefore GAd
Induced alfaxalone, main. 02/iso
Sx: both AGs expressed; both had small plugs that once dislodged allowed normal emptying of light green/grey liquid.
P: TGH w meloxicam/clavulox.
    r/c if concerned.
    ST Daughter (Michelle).

O called for more meloxicam. Okayed AH as per RP instructions. Dispensed AL. 
Pls send through ins once paid.
15/09 meds collected, ins. claim sent via vethub, EN.

Presented for: RC
Butt looks amazing. No more blood or lesions.
BAR MM pink. CRT <2sec. 
LN: WNL
Cardio: HR  normal rhythm, murmur as noted previously
Pulm: clear
Abdo: so pendulous 
Temp not taken
A: Rectal exam, all normal, comfortable. no blood and also AG size normal 
P: Keep gooing with rest of abtics and also keep going with meloxicm for QOL
Gave RRR diary to monitor heart disease 

Insurance submitted via vethub MJ