C09996892 / invoice 10000

HISTORY:Presenting complaint: Left leg sore. noticed since januarya. Improved slightly, Diet: eating well, toileting ok. Vacc: Worming/Heartworm: Flea control: Comorbidities/current medications:EXAMDemeanour: BCS /9Cardiovascular: Heart valves clear, Pulses strong and synchronous, HR 126Respiratory: clear lung fields Temp: not takenMM colour/CRT:  pink, moist, CRT <2sDental: Ears: Externally NADEyes: NAD LN: NADSkin: NAD Abdominal palpation: soft, no pain, no masses appreciatedMusculoskeletal: Rectal exam: Hydration status: ASSESSMENT/Problem List: TREATMENT:CLIENT COMMUNICATION:

The intention of the following template is to clarify the minimum requirements for veterinary notes. This should not be used if it is a first claim as it will likely go on hold for more information required. GapOnly claim Insurance Summary First Clinic Signs:Head tilt and head haking 3 days duration. Summary:Sedation required to enable appropriate otoscopic examination of the ear. Foreign body or infection unable to be appreciated. Further work up is required to determine cause of head tilt. PlanRevisit 48hrs- no treatment at this stage. 

Pre GA check:Demeanor HR  RR    Temperature  Physical Examination - mucous membranes pink, crt < 2 sec, teeth WNL, ears normal, eyes normal, lymph nodes normalheart and lungs - normal rate, rhythm and no murmur, lung fields clearno abnormalities detected on abdominal palpation, temp normalhydration status: Abnormal findings:ASA patient classification : I/Premed: Butorphanol (0.17 ) ml  + medetomidine (0.03ml) IM sedation at (3:10 )pmMaintenance isoflurane and monitoring with veterinary nurse, SpO2 / HR, NIBP, ETCO2GA comments: Uneventful. Hair pulled form within ear canals bilaterally. No infection or foreign body could be appreciatedDischarge instructions given to owner