C10010012 / invoice 10000

Reason: Admitted for lump removal, pre ga bloods:
See prv hx below:

Premed:
Domitor: 0.29mls IM
Methone: 0.89mls IM
Co induction with Ketamine: 0.14mls IV
Induced with Propofol IV


PROCEDURE:

Intra op complications:
Recovery:

Post op meds:

Plan:
Discharge this afternoon
FUC in 24 hours
POC 5 days

Reason: Lump:

O has noticed a lump on the anus approx 1 week ago:
O has noticed is hesitant to sit at times:

BAR EDUF all ok at home
No V or D
Current meds:
-Cytopoint at times: last given early Janua

Mm pink, crt 2s
PLN nad
HR 104
RR 38
Nsf on abd palp: s and c
LUMP:
Left dorsal anus area: small (1cm x 1xm), raised, alopecic, soft tissue mass, no signs of ulceration

Assessment
Soft tissue mass: ddx: adenoma

Plan:
-Have advised surgical removal: with KS only as requested
-Estimate required: no histo:
-Has been booked for Tuesday 10th March: premed to be given with O present

Reason: Cytopoint injection

PE: 

-Mentation: BAR, nice boy, just not dog friendly
-Eyes: NAD, clean and clear
-Ears : clean and clear
-Nose: NAD
-Mouth: NAD
-Teeth: lovely, but worn in molars with + plaque
-Dental Grade: 1 Would suggest dental if having GA for any other reason, but not a huge rush. 
-CRT: <2sec 
-Mmbe colour: pink 
-Skin tent: normal
-Coat: healthy
-Skin: Pedunculated lump to RHS belly, and a couple of small skin tags to belly.
-Lymph Nodes: NAD
-HR: 110
-Chest: No abnormal sounds auscultated
-RR: 36
-Abdomen: NAD, no pain palpable
-Temp: not taken today
-Femoral Pulse: normal 
-Rectal Exam: not performed today 
-Anal Glands: not examined today
-Nails: not trimmed
-Gait: normal 
-BCS:  5/9 
-Other details of interest?: Pruritis has been really good, but just recently flared (more chewing). Hasnt needed a dose for many months. 

Tx:
Cytopoint 40mg

Plan: Cytopoint as needed (by nurses)