C10009777 / invoice 10000

Reason:Vulvaplasty sxHistory: EDDU normally, well at home, BAR, no v or d. Fasted overnightCurrent medications/Supplements:- Allergy injections (from Dermatologist) - Prokolin (previously) Medical conditions:- Persistent urinary signs- Inverted vulva- Suspected urinary incontinence- Anxiety- Skin hypersensitivitiesExamination: Appearance - BARCardiovascular - no murmur or arrhythmias, pulses strong and synchronous Respiratory - no crackles, no wheezes, eupnoeic GIT - NAD on abdo palpation, comfortable, no hernias detectedOral – NAD, no retained deciduous teeth Genitourinary - no vulval discharge or swelling Assessment: Fit for sxLaboratory:Bloods taken at previous consult - see visit 29/1/26Anaesthesia: PreOp -> ACP 2 0.8ml + Methadone 1mL given IM @ 10:02amInduction: Induction with Propofol  IVMaintenance: Inhalation - with Isoflu + O2 via Circle circuit, size 7cm ET TubeComplications:No anaesthetic complications, smooth recoveryIV Fluids:Hartmann's running @ 160mL/hr during GA. Surgery: VulvaplastyCresent shaped skin removed dorsal and either side of the vulvaSkin closed with 3-0 premelinClipped nails.Refer to paperchart for GA monitoring informationMedications:Given - Metacam inj 1.20mL given SC @ (XXX)amTGH w/ - Metacam 2.5mg, 1.5 tab SID starting Wednesday after 12pm. Client Communication: phoned hazel . Surgery went well, discussed can be quite irritated post surgery, need to make sure not scratching licking etc. Should help reduce recurrance of bladder infections but still need to look out for incontinence and itchy skin, home 3pmPlan:TGH w/ post op notes & e-collarTGH w/ medication, see aboveR/V in 3 & 14 Days for post op checks s/r with a Nurse    Vital Signs    Weight: 32.8;       RespirationRate: panting ;       CRT: <2;       MMColour: pink;