C09996703 / invoice 10000

Hx: Riki went to groomer on Monday, Groomer noticed a lump on him. Did not notice anything different about Riki prior to this. No behavioural changes have been noted. Not bothered by the lump. EDDU normally. Ex:Mentation: BAR, ate treat during PE. Integument: A pink colour fixed lump on the RHS lower lip region. No obvious discharges or broken skin noted. Ax:Problem 1: Pink colour lump at the R lower lip region Tx:Emla cream applied onto the site. Disinfected with iodine. FNA performed using grey needle. Straw colour like fluid aspirated from the site. Sample sent to QML for cytology analysis. Px:awaiting cytology result for further treatment plan.     Vital Signs    

Presenting complaint: Annual C5 vax and SR12 Hx: - EDDU normally. Ex:    Vital Signs    

Presenting complaint: Dental tx Hx: o reported that Riki has been well. Eddu normally. No recently v+ or d+ has been noted. Currently on mix of wet and dry food. UTD with prophylaxis tx. Ex:Mentation: BAR, anxious BCS: 4/9Dental grade: 2/4Menace and palpebral response: unremarkable Neuro: No nystagmus or head tilting behaviour noted. No ataxia or circling gait noted. Full neuro exam not performed. Eye: Unremarkable  Ear: unremarkable  Cardiovascular: No obvious heart murmur detected. Heart rate in synch with femoral pulse Respiratory: Normal BV sound. No increase in respiratory effort noted. Peripheral lymph nodes: peripheral LNs are normal in size, and no firm or painful LNs were noted.  Integument: Coat shiny and no alopecia noted. No obvious ectoparasite noted.  A small skin tag present at the chin region. Abdomen: Soft and comfortable on palpation. No palpable organomegaly, masses, or other obvious abnormalities Spinal palpation: No obvious discomfort noted during spinal palpation. No neck pain noted during active ROM. MSK: Weight bearing on all 4 when ambulating in the examination room and clinic. Urogenital: Unremarkable Rectal: No performed. Laboratory: Pre-GA blood performed with sedation on board. Mild elevation of ALP. Ax:Riki is fit for dental tx under GA Tx:Riki is admitted into hospital for dental procedure Sedation of Methadone 0.3mg/kg and Medetomidine 5mcg/kg administered via sc. Mild sedation achieved. IV catheter placed onto the L cephalic vein.  Hartmann’s fluid was administered at 6ml/kg/hr. GA administered via titration of the Alfax to  effect. Intubated with size 6.5 et tube. Maintain on Isofluraine. Dental assessment performed. No extractions required. Monitor of 206 there is exposure of furcation point however the tooth is still sturdy.  Also monitor of 401 and 301 due to gingival recession. however still sturdy Teeth scale performed. The teeth polished with profie paste afterwards. Nail trimmed and anal gland expressed Recovered from anaesthetic uneventfully. Ate BBQ chicken when regain full consciousness . Contacted O over the phone to inform the status of Riki. Discussed post anaesthetic care and things to monitor for such as vomiting and diarrhoea and shaking behaviour as well as dental preventative and husbandry with O at discharge. Px: D/C home into O’s care without complication.     Vital Signs    Weight: 10.25 (Patient Update);