C09979010 / invoice 10000

WEIGHT: 36.00
HISTORY: Reason: Dog Fight Wound

History:
- has been bitten by the neighbour's dog three times in the last 6 months
- this time was bitten on the head over the right eye and has developed a significant cellulitis

Examination:
Mentation: BAR,
Vitals: all wnl, temp 38.2
BCS: 4/9
Eyes:
Right: PLR normal, anterior chamber quiet, nil fl uptake, IOP = 18mmHg
Oral: grade 1 dental disease
Nose: clear,
Ears: NAD
C-V: no murmurs or arrhythmias, peripheral pulses are strong and synchronous
Resp: lung fields all clear
GI: NAD
Rectal exam: not performed
U-G: unremarkable, 
Musculoskeletal: NAD
Neuro: NAD
Skin: bote wound on top o fhead, cellulitis +++ but no identifiable pockets of pus
Lymph nodes: NAD

Assessment:
Dog bite cellulitis

Treatment:
Curam Du Forte x 1 tab BD for 10 days
Carflexin 50mg Po BD for 10 days

WEIGHT: 33.00
HISTORY: Reason: Lumps

History:
- new patient with uneventful medical history except for having a tumour removed from over right scapula in 2021 (mass never sent for histopath)
- has developed a firm swelling on back of neck and just ot LHS of neck
- also had a few hot spot near caudal dorsum to which O applied and they have healed

Examination:
Mentation: BAR,
Vitals: all wnl, temp 38.4
BCS: 4/9
Eyes: NAD
Oral: grade 1 dental disease
Nose: clear,
Ears: NAD
C-V: no murmurs or arrhythmias, peripheral pulses are strong and synchronous
Resp: lung fields all clear
GI: NAD
Rectal exam: both anal glands very full, easily expressed, no masses palpable
U-G: unremarkable, 
Musculoskeletal: NAD
Neuro: NAD
Skin: swelling as described above measuring 6/6cm and 5/5cm respectively, swelling located to LHS of neck has a bite/puncture mark over it
Lymph nodes: NAD

Laboratory:
FNA of both swellings retrieved purulent/haemorrhagic fluid containing neuts with intracellular cocci +++

Assessment:
Abscesses. Possibly from play fighting with other dog?
Recommended surgical drainage but O wants to trial medical management first

Treatment:
Amoxycalv 500mg BD for 7 adya s= ccarflexin 50mg PO BD for 7 days