C09987396 / invoice 10000

Reason: Prolonged SeasonAppointment Notes: Overdue remindersHISTORY:  Presented for being flat and quiet. Has been in season for approximately one month since mid-February 2026, which is a longer duration than her usual three-week cycle. She is still eating but is not her usual self, appearing lethargic with her head down. Ongoing vaginal disharge - blood clots Current meds: noneVaccination: Not mentionedParasite Prevention: Not mentionedPre-existing conditions: noneAccess to toxins eg. Rodenticide: none TRIAGE: Temp: 39.3 degrees celciusDemeanour/Behaviour: BAR in clinic EXAMINATION:Body Condition Score: 6/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:Oral: normal, no mouth pain, dental score (1-4):2Abdominal: mild abdominal distensionRectal: not performedUrinary: NSFReproductive: serosanguinous discharge from vulva + blood stainingIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: BAR PROBLEM LIST:LethargyPyrexia (39.3°C)Prolonged oestrus (~4 weeks)Fluid-filled uterine horns on ultrasound DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Open pyometraCystic endometrial hyperplasia DIAGNOSTICS:Diagnostic Imaging: Abdominal Ultrasound was performed.Bladder: normal bladder wall with anechoic urine. Multiple anechoic, tubular structures consistent with fluid-filled uterine loops are visible adjacent to the bladder.Interpretation: Findings are consistent with an open pyometra, with multiple fluid-filled uterine loops identified.  ASSESSMENT: Dolly presented for lethargy and a prolonged heat cycle. Examination revealed a mild pyrexia. An abdominal ultrasound confirmed the presence of multiple fluid-filled uterine loops, consistent with an open pyometra. Although not currently an emergency as the cervix is open, surgical intervention is indicated. TREATMENT:  Initiated antibiotic therapy with clavulo - 750mg BID Discussed avoiding NSAIDs due to the risk of exacerbating potential renal compromise from endotoxaemia.Paracetamol 500mg BID PLAN:Recommended surgical intervention (ovariohysterectomy) this week.Home into owner's care on antibiotics pending surgery. CLIENT COMMUNICATION:Discussed the diagnosis of open pyometra with the owner, Paul. Showed ultrasound images and video of the fluid-filled uterus. Explained that while her condition is not an immediate emergency, surgery is the definitive treatment and should be performed soon. Advised on antibiotic therapy and the rationale for withholding anti-inflammatory medications. Plan for surgery this week was discussed and agreed upon.    Vital Signs    MMColour: p+m;       Weight: 40;       Temperature: 39.3;       HeartRate: 96;       BodyScore: 6/9;       DentalGrade: 2;       RespirationRate: pant;       CRT: <2secs;