C10013813 / invoice 10000

NURSE: AC 

REASON: wound check post dental 

HISTORY: 
doing well at home 
no worries or concerns 


SURGICAL SITE:
Extraction site 204 
healing well 
small amount of suture still present 
Very small pocket still present but very minimal 

ASSESSMENT:
healing well 

PLAN:
Hold off on hard food for another week 
Otherwise ok to go back onto normal diet 

**
NURSE: HM 

REASON: Dental RV 

HISTORY:
- Owner reports the patient was a bit sore for the first few days post-op but has been back to her normal self for the last couple of days.
- Eating softer food (prime 100) in small bits without issue. 
- Owner is hoping to reintroduce harder foods like kibble and carrots.

APPETITE: WNL 
ACTIVITY: WNL
DIET: Prime 100 
TOILETING: WNL
CURRENT MEDICATIONS: 

CLINICAL EXAMINATION:
Mentation: BAR
MM: Pink, moist 
CRT: < 2sec 
Oral Exam and Dental Score: Examination of the mouth revealed an impacted bit of food at the upper canine extraction site. The flap has broken down, which is not infected but will take longer to heal. The site looks healthy otherwise. The other extraction sites are healing well. 
Skin: Owner noted increased moulting. Coat can change with age, and shedding can be seasonal. No fur patches or significant hair loss noted. Brushing may help.

ASSESSMENT:
- Wound breakdown over 204 
- Other extraction sites healing well 

DISCUSSION:
- Discussed with the owner that the breakdown of the canine flap is not infected but will prolong healing. It makes the site more prone to food getting stuck. The rest of the mouth is healing well.
- Advised to hold off on feeding very hard foods like carrots for another week. Normal biscuits should be fine.
- The owner consented to a follow-up nurse recheck in one week to recheck site - can also clean out area of any impacted food at home. 

PLAN:
- A nurse recheck has been scheduled in one week to assess the healing of the canine extraction site.
- If the owner is able, they can check and wipe the area at home.