C10032939 / invoice 10000

Reason: Consult AdmitSHIFT CHANGE ~ 1230-1500 VET: Jennifer Voss ASSESSMENT:  BAR, anxious! But friendlyHeart and lung sounds wnl'sAmbulation wnl'sNo active bleeding from RHL TREATMENT:Aceprom 0.02 mg/kg s/q and methadone 10 mg s/q -> inadequate sedation to place IV Dexmedetomidine 250 mcg IM; adequate to place IV, however Louie still required gentle restraint to place IV IV placed Cefazolin 22 mg/kg IV @ 1400, 1600 SURGERY:Induced via alfaxalone, intubated via 9.5 ET, maintained on iso, o2 and fluidsLaceration to RHL, medial interdigital edge of P2 foot padFull-thicknessMinor dirt debris within, otherwise tissue healthy; estimate wound <6 hours old Fluid wound with copious sterile salineClosed s/q via 3-0 SC Closed dermis via 309 SI and cruciate; Since 4-0 PDS mono SI placed at palmar edge Limb bandaged via cotton between toes. Melonin along suture sites. Softban, crinx, vetwrap, elastoplast proximally and distally  PLAN:Transfer to evening vet for ongoing treatmentD/c appt arranged for 5 PM TGH ongoing antibiosis and analgesia.Remove bandage Sunday PM E-collar 24/7 Se RV in 7-10 days for s/q O Contacted and Bill update (Y/N):~ 4 PM, updated on progress and spoke about sx findings. Arranged d/c home for 5 PM    Vital Signs    

TIME: 12:20VET: GNHISTORY:Cut RH foot/pad this morning- unsure what happenedWell in himself, EDUD normal Ate 6.30amCurrent meds: NILProphylaxis: utdPre-existing conditions: NILAccess to toxins eg. Rodenticide: NILTRIAGE:HR: 124RR: 28Temp: n/tMm: pink moistCrt: 1-2Mentation: BARPain Scale (0-4): 2Hydration status (%): 0-5EXAMINATION:Body Condition Score: 5/9Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint pain. RH foot has blood on it- pad on D2 is partially torn off and webbing has been lacerated aswell. Deep lacerationGastrointestinal:- Oral: normal, no mouth pain - Abdominal: no detectable pain on abdominal palpation, normal gut sounds- Rectal: n/aUrinary: n/aReproductive (incl ext genitalia): n/aIntegument/Ears: NSF, not scoped earsLymph Nodes: peripheral lymph nodes normalEyes: NSFPROBLEM LIST:Pad laceration with some webbing affected aswellDIAGNOSTIC/MANAGEMENT PLAN:Admit for GA, surgery to debride and repairHave warned o may need to remove lacerated part of pad, and warned re difficulty in healing when sutured.Will need bandaging and rest**HANDOVER TO JV**    Vital Signs    Weight: 34.2;