C09970108 / invoice 10000

DATE/TIME of CONSULTATION: 13:23hrs, Sat 28/02/26
CLINICIAN: JC 
PRESENTING COMPLAINT: abscess on neck 

HISTORY: brought in by o's son. 
o is away at the moment - just flew out today
spoke to her on the phone to take history
sebaceous cyst on R neck there for the past two years
was given needles and syringes for o to drain at home
was doing it every 3 months or so and more recently increased frequency to every 6 weeks 
two days ago drained it and was clear fluid as normal
noticed it had grown in size (normally at most is size of 20c piece) 
drained again today and its thick yellow creamy stuff - worried about infection 
didn't eat much this morning but otherwise seems ok 
not currently on any meds 

CLINICAL FINDINGS:
mm pink 1 sec
slab fracture upper R carnassial - incidental finding but news to owner 
HR 80. normal rhythm and no murmur
RR 16. normal resp rate
lovely temperament and chilled out 
abdo comfortable
temp 38.0
subcutaneous swelling on R lateral neck area approx 8cm diameter ovoid in shape
clipped fur over the top - no skin wounds overlying
fna = mucoid yellow material. drained about 20 ml with ease. not able to completely empty

DIAGNOSTIC TESTS:
SG of fluid 40g/L
grossly does not look or smell typical of pure purulent material
grossly more of a mucoid sticky conistency
cytology = neutrphils in proteinaceous background. no organisms seen

DIAGNOSIS: infected cystic lesions on R neck 
TREATMENT: 7 day course oral clav 
CLIENT COMMUNICATION/PLAN: review with reg vet at end of course  

Update: 

Dusty has been using his left hind a little better over the last couple of weeks which is pleasing. Follow-up radiographs today indicate that healing has progressed significantly with bony fusion. 

I have recommended that he be exercised more, along with further pain relief to encourage further muscle build-up. The Skurries will start to walk him twice daily for 2-3 kms and allow some off leash activity and play with their other Goldy. 

You may view the images on Purview, our cloud-based PACS server, via this link: https://image-ase2.purview.net/instantshare?jwt=enc01-yHqGVAJ-Dif6IdAfcB03SP9Hcr1NIJPaVuojfrE3eXd4y-rOAIspC94BD0MIYm4A