C10010506 / invoice 10000

Dispensed gaba and acp prior to vet visit Advised am appt, and fast as she can be difficult to examine and may need further sedation Wedding on Friday so please do all on one day if poss

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 shaking and itching noticed yesterday. History of grass seed issue- requires sedation for further examination. Summary:Sedation for otocoptic examination and grass seed removal. Diagnosis:Foreign Body with secondary otitis externa Treatment:Sedation + Antipamezol reversalGrass seed removalNeptra medication into left ear

Pre GA check: WNL Demeanor  BAR HR 136  RR panting   Temperature   normalPhysical 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: WNLAbnormal findings: nil ASA patient classification : I/Premed: Butorphanol (0.25) ml + Medetomidine (0.18ml) sedation at (10:00)amMaintenance isoflurane and monitoring with veterinary nurse, SpO2 / HR, NIBP, ETCO2GA comments: (uneventful GA)LEFT ear: moderate debris noted within ear canal- 1x grass seed removed. 10 yeast per HPF.- Neprta applied. recheck in 1 month. RIGHT EAR: moderate debris and erythema in horizonal ear canal. Discharge instructions given to owner