C10020059 / invoice 10000

NOTES: Mild haemolysis
High GGT (24, 0-9)- likely affected by haemolysis. All other liver and GB parameters wnl.

NOTES: Presented today for sedation to perform examination, screening bloods and administer vaccination/trim nails. Has been head shaking today. 
Anxious/reactive during vet visits. Has had Trazodone 200mg + Gabapentin 1000mg PO last night and this morning. A little sedate/sleepy in the car at home. Alert in clinic.
O has size 3 muzzle and has tried muzzle training at home- Roger is reactive with the muzzle and will snap/bite when introduced.

Physcial exam:
BAR, friendly on introduction but vigilant and will snap if handled near facial region/with restraint.
BCS 5/9- ideal.

Treatment:
1. Medetomidine 0.4ml + Butorphanol 0.8ml administered via IM injection (this is the previous reportyed dosage that was effective in achieving a good level of sedation). Performed this in the outdoor courtyard looking out the gate with a door as barrier. Vocalised. After 20-25 minutes minimal response. Still ambulatory and reactive
2. Additional 0.8ml medetomidine administered IM. This led to a deep level of sedation after ~20 minutes. Still occasionally reactive- caution when handling. Placed a muzzle for safety using slip lead over nose prior. 
3. IV cath placed RHL and blood collected from this site for TAHP. Sending to IDEXX
4. Examined ears. L ear NAD. R ear small vol erythemic/mild haemorrhage present adjacent to TM on ventral aspect. No FB detected. Scab performed- no organisms detected. Flushed with sterile saline.
5. Trimmed nails
6. Reversal with Antipam 1.2ml IM.

P:
1. Recommend treatment of ear inflammation/ulceration with Meloxicam PO SID for 7 days
2. Awaiting blood results
3. Behaviour- recommend basket muzzle (may need custom fit) prior to future visits. Also consider trialling alternative PVPs- clonidine etc.

BLDRQ: N
WRMRQ: N
HISTORY: Gabapentine for ongoing stressful situations and pvps
FLRQ: N