C09971037 / invoice 10000

DATE/TIME of CONSULTATION: 20:25hrs, Sun 01/03/26
CLINICIAN: Josie Sinclair
PRESENTING COMPLAINT: lethargic, sore
HISTORY:
- Lethargic today - sleeping more than usual
- Seems painful around peri-anal region
- Large amount of discharge (pus? diarrhoea?) around back end
- Given Gabapentin around 7pm

- Eating a little less than usual
- No vomiting, possible diarrhoea
- Indoor only, one other cat at home (typically get along)
- No current medication

CLINICAL FINDINGS: 
EENO: MM pink and moist, CRT <2s, otherwise WNL
Cardio: HR 160, no murmur or arrhythmia
Resp: RR 28, no abnormalities on ausc
Abdo: soft and comfortable
MSK: no lameness or pain on palpation
Neuro: BAR, fractious with handling, no obvious deficits
Integ: large, bruised, draining abscess over RIGHT anal gland

PROBLEM LIST:
1. Anal gland abscess
2. Lethargy

OPTIONS PROVIDED:
a) Sedate for clip + clean and flush of abscess 
b) Start ABs and NSAIDs and clean at home
O elected option A. Requested to run full bloods while anaesthetised.

DIAGNOSTIC TESTS:
Haematology:
- NEU 11.3 (2.3-10.29)
- EOS 0.13 (0.17-1.57)

Biochemistry:
- Urea 5 (5.7-12.9)

Electrolytes
- All WNL

TREATMENT:
Sedated with 0.1ml butorphanol, 0.1ml medetomidine, 0.1ml ketamine IM (restrained by O).
Abscess clipped and cleaned with dilute chlorhex, and flushed with sterile saline.
Rectal exam under sedation found empty anal glands, but a 3x5cm firm SC mass dorsal to the right anal gland/abscess. 
2x FNA taken of mass - submitted to Aurora for cytology.
O to give Clavulox (12.5mg/kg PO BID 7d) and Meloxicam (0.05mg/kg PO SID 5d) at home.
Ongoing plan pending cytology findings. Discussed risk of non-diagnostic given local infection.

Sedated zoletil 0.1ml SQ to take bloods
Type B
Not compatible, as Amber is Type A