C09982498 / invoice 10000

Presenting Complaint

Recheck RHS temporal/head swelling following previous diagnosis of suspected deep soft tissue abscess. Finished first course of antibiotics and meloxicam today.

History (Owner Report)

Swelling initially identified last week.
X-rays and ultrasound performed previously.
Abscess ruptured spontaneously on Sunday with discharge of blood/pus.
Since rupture, swelling significantly reduced.
Eating well.
Bright at home.
No vomiting/diarrhoea.
Completed course of amoxicillin/clavulanate and meloxicam today.
Owner reports previous similar abscess in throat region in past (grass seed suspected) requiring surgical removal.
Now insured.
Oral liquid medication difficult to administer (meloxicam disliked).
Tablets easier to administer now that discomfort reduced.
Owner keen to avoid CT or surgery if possible.

Physical Examination

BAR
Swelling RHS temporal region — small residual firm swelling present
No obvious fluctuant pocket
No active discharge
Much improved compared to initial presentation
Non-painful or minimally reactive on palpation
Jaw opens normally
Eyes normal, no retropulsion pain noted
Ears NAD
Temperature not elevated
No significant lymphadenopathy

Assessment

Improving RHS temporal abscess, likely deep soft tissue infection.
Good response to first antibiotic course.
Small residual swelling suggests ongoing resolving inflammation ± small remaining infected pocket.
Given marked clinical improvement, no pain, no pyrexia, and no active draining tract, conservative management is appropriate at this stage.
Foreign body still remains a differential if recurrence occurs.

Plan

Extend antibiotic course.
No further NSAID required at this stage (completed today).
Monitor closely.

Medication Dispensed
Noroclav/Amoxyclav 50 mg tablets
Give 2 tablets twice daily for 7 days
Total: 28 tablets
(Tablets chosen instead of liquid for easier administration.)

Client Communication

Discussed:
Good improvement since rupture.
Small swelling remains.
Possible underlying foreign body still cannot be fully ruled out.
If swelling increases again after stopping antibiotics, surgical exploration or advanced imaging (CT scan) may be required.
Goal is to avoid surgery if infection resolves fully.
Recheck booked in 7 days (10:20 am next Tuesday, 10/03/2026).
Owner understands and agrees with plan.

Prognosis

Good if resolves fully with second antibiotic course.
Guarded if recurrence (foreign body likely).