C10003755 / invoice 10000

Reason: Unsettled Post Anal SaculectomyHISTORY:  Presented for assessment of post-operative pain. Roxy underwent an anal saculectomy on 06/03/2026. Owner reports whimpering and panting today, which persisted for approximately three hours despite one dose of gabapentin. The owner was not concerned about minor oozing from the surgical site as this was expected. The primary concern is the level of discomfort. Current meds: Metacox (anti-inflammatory), Gabapentin (one dose given at home).Prophylaxis: UTD.Pre-existing conditions: noneAccess to toxins eg. Rodenticide:none TRIAGE: HR: 120RR: pant Temp: x not taken Mm: pink, moist Crt: <2Mentation: BAR EXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 1/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, no murmur detected, normal rhythm, pulse pressures normal and synchronousRespiratory:thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological:normal mentation, cranial nerves intact, ambulating well with no CP deficitsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:Oral: normal, no mouth pain, dental score (1-4):1/4Abdominal: no detectable pain or organomegaly on abdominal palpation, normal gut soundsRectal: Not performed.Urinary: NSFReproductive: NSFIntegument/Ears: The anal saculectomy surgical site was clipped and cleaned. The site appears good, with no signs of significant inflammation or infection. Suspected mild irritation. no ectoparasites or lesions noted. Ears free of overt discharge.Lymph Nodes: peripheral lymph nodes palpate within normal range.Eyes: Bilaterally clear with no discharge PROBLEM LIST:Post-operative pain/irritation following anal saculectomy. DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Suspected mild post-operative irritation vs inadequate analgesia. DIAGNOSTICS:None ASSESSMENT: Roxy presented for assessment of discomfort following a recent anal saculectomy. On examination, she appears comfortable and her surgical site looks good, suggesting mild irritation rather than significant pain or complication. Her weight is 20kg. TREATMENT:  Discharged home with additional analgesia.Trazodone 100mg dispensed. Dose is one tablet every 8 hours. Owner advised this can be increased to 1.5 tablets if needed.Paracetamol 500mg dispensed. Dose is 3/4 of a tablet every 8-12 hours. PLAN:Continue current medication (Metacox). Administer Trazodone and Paracetamol as prescribed for comfort.Roxy has a scheduled recheck appointment with her primary vet. Owner to continue with this appointment.Home into owner's care. CLIENT COMMUNICATION:Discussed that Roxy's discomfort is likely due to irritation rather than severe pain. Explained the use of Trazodone as a sedative to help with anxiety and irritation, advising it takes about one hour to take effect. If sedation is inadequate after one hour, an additional half tablet can be given. Advised on the addition of paracetamol to her current pain relief protocol to improve comfort. The plan is to continue current medications and attend the scheduled recheck with her primary vet. Advised to give Trazodone and Paracetamol tonight and tomorrow morning.    Vital Signs