C09971637 / invoice 10000

Clinical Notes. Comms team to paste into OpenVPMS.
Completed by: Dr Vetland Emergency
Presented on 26/02/2026
HISTORY
Presenting complaint:
- Hole/wound on Bonnie's shoulder
Diet and appetite:
- Not discussed.
Current medications & medical conditions:
- Zactive administered for years; no reported adverse reactions or allergies to medications.
History of presenting complaint:
- Owner unsure how the wound occurred.
- Discussion suggests a possible scrape against a rough surface during running or playing.
- No known recent trauma or incidents observed.
- No other dogs in the household.

PHYSICAL EXAM
Mentation: BAR
Eyes: NAD
Ears: NAD
Nose: NAD
Oral: pink mucous membranes, CRT <2 seconds
Lymph nodes: NAD
Cardiac: NAD
Respiratory: NAD
Abdominal: NAD
Genitourinary: NAD
Musculoskeletal: NAD
Neurological: NAD
Skin & Coat:
- Wound/defect on shoulder noted; outer edges not clean, suggesting abrasion.
- No description of ectoparasites, additional lesions, or masses.
- See photo attached on SmartFlow.
Anal Sacs: NAD
Temperature: NOT TAKEN
Body Condition Score: NOT MENTIONED
Notes:
- Patient tolerated cleaning and handling well.
- No other abnormalities noted.
- No evidence of other wounds on examination.

DIAGNOSTICS
Clinical Examination

ASSESSMENT
- Open wound/abrasion on the shoulder
- Possible contamination of the wound
- Risk of secondary infection or necrosis at wound edges

TREATMENT
- Bonnie administered a strong opioid painkiller
- Injection of anti-inflammatory medication given
- Wound cleaned and decontaminated
- Oral antibiotic prescribed
- Activity restriction advised for the next few days
- Owner counselled on restricting outdoor activity and supervising Bonnie when outside
- Wound to be re-assessed in 3–4 days to monitor for signs of infection, delayed healing, or tissue necrosis

COMMS
- Owner clarified uncertainty about the origin of the wound
- Owner asked about Bonnie’s tolerance to clippers; unsure
- Discussed possibility of future wound management if necrosis or infection occurs
Differential diagnoses:
- Acute traumatic abrasion, secondary wound infection, foreign body contamination
ADDITIONAL INSIGHTS: None