C10032473 / invoice 10000

Reason: Ate Grapes    Vital Signs    Weight: 9.7;       

Reason: Dog Bite Wound - EarHISTORY- Four year old male neutered dog attacked by another dog whilst walking past property- Other dog jumped on and bit patient- Owner concerned about infection risk- Dog walking normally and eating well post-incidentVITALS:HR: 120RR: PantingTemp: 38.7°CMM: Pink and moistCRT: <2 secondsMentation: Bright, alert, responsiveExamination:Cardiovascular: NAD - normal rate and rhythm, no murmurs or arrhythmias auscultated, pulses strong and synchronous.Respiratory: NAD - no nasal discharge noted, normal respiratory rate and effort, bronchovesicular sounds are normal to all fieldsNeurological: NAD - normal gait, posture and mentation; full neurologic exam not performedGastrointestinal:- Oral: Oral mucosa appears normal, no lesions noted.- Abdominal: Normal on abdominal palpation, no obvious masses noted, comfortableMusculoskeletal: NAD - no evidence of lameness or pain. Full MSK exam not performed.Ears: NAD - pinnae normalEyes: Eyes clear with no obvious discharge or changes associatedLymph Nodes: NAD - peripheral LNs normal in size, no firm or painful LNs identifiedUrogenital: NADIntegument: Superficial wounds to Left ear, otherwise NADPROBLEM LIST:Dog bite wound TREATMENT:Meloxicam 0.1mg/kg PO q24Amoxyclav 200mg PO q12Plan:Re-assess with primary care vet as required.    Vital Signs    Weight: 9.8;