C10020794 / invoice 10000

Reason:  check nail
History: 
O heard yelp last night.
O noticed dewclaw on L side cracked 
Could not get good look at it as star tried to bite
O unsure of when injury happened or how she could've torn nail
Otherwise eduf normal

Current medications: none

Examine: 
Mentation: BAR, had to muzzle for nail exam 
Body condition score:5/9 
MM:  pm              CRT: <2s
HR: 112               RR: wnl
LN: wnl
Temperature: ne due to demenaour

Ocular: nad
Oral/Dental stage:s1-2
Ears: nad
Cardiovascular:no murmur/arrythmia 
Respiratory: nad
Gastrointestinal:comfortable 
Integumentary & lumps (measurement, location):Lfl dewclaw: cracked all the way through mid way through nail, end of nail hanging. Inflamed area, slight green discharge seen.
Musculoskeletal: ambulatory on all 4 limbs
Urogenital: nad
Neurological: nad

Sprayed lignocaine on LFL dew claw, pulled with forceps easily. Bleeding stopped with pressure. Cleaned with beatdine 

Problem List:
Torn LFL dew claw
ddx trauma 

Assessment: 
Discussed AI and AB as unknown timeline of injury.

Treatment: 
Clav 100mg BID
carprofen 10mg BID 5d 

Plan: 
ecollar 
Recheck in 3-4 days to see healing 
On-going medications required: Y/N (use prescription tab for further supply):

Followup: 

Reason:
Consult Nurse:
History:
     EDUF:
     Nutrition:
     V#/D#/Coughing?
     
What Preventative health cover is being used and do you need to purchase any today?
Vaccination:
Worming: 
Flea control: 
Heartworm Prevention: 

Examine:
     General Appearance:
     Body Score:
     Coat/Skin:
     Ears/Eyes:
     Dental Stage:

Microchip:

Assessment:

Treatment:

Email Sent:

Next Appointment: