C10013312 / invoice 10000

Reason:
checkup
History:
noticed discharge from penis lastnight, cleaned and none this morning, 
edud ok 

licking feet more than usual for the past week 
went to groomer a week ago

Dehydration assessment: Euhydrated MM moist no skin tent

PHYSICAL EXAMINATION:
Appearance: BAR; BCS 4/5
Eyes: nad
Ears: nad
Integument: 
Peripheral LNs:Normal size, symmetrical
Urogenital:no wound. or discharge. 
Assessment/Problem List:
smegma?
allergy?
Treatment: none

plan: O to monitor for now. 

Reason: 

History: 

Exam: 
Temperature: C, Heart Rate:  bpm  Pulse rate: bpm
Pulse character: strong and synchronous. Respiration Rate: . 
MM:pink/moist  CRT: 1 sec

PreGA Blood test: 

PreMed:

Induction:

Maintenance:
Fluid: 
ET tube:

Monitoring nurse:

Intra-operative  patient  monitoring used during this procedure included  SpO2, indirect  blood pressure, ECG, heart rate and temperature.

Procedure:

Recovery: 

Medication: 

Discharge Plan: 

Reason:  check lump on ear 

History:  ear infection, on dermotic for past 2 days , lump on left ear pinna 

Vital Signs: wnl

Dehydration assessment: Euhydrated MM moist no skin tent

PHYSICAL EXAMINATION: very anxious dog, hard to examine without sedation, can see dried blood middle of lrft ear pinna on dorsal aspect 

Treatment:  gently clipped hair as much as we could, and cleaned the area, ulcerated burst abscess/mass 

Plan:  most likely sebaceous cyst or adenoma, should be able to treat it with histofreeze but needs to be done under sedation