C09987735 / invoice 10000

REASON: Presentation for a ruptured abscess on the back.HISTORY:- An abscess or cystic-like structure has been present on the back for the last six months. This has been a known issue and was previously not a concern, and he had not been bothering it.- A fine needle aspirate was reportedly performed in the past with no evidence of neoplasia found.- This afternoon, irritation with the lesion developed, leading to scratching.- The lesion subsequently burst and was bleeding.- Eating and drinking have remained normal.- There has been no vomiting or diarrhoea.- Pre-existing conditions: A grade three out of six heart murmur was noted on clinical examination.- Access to toxins: No known access to any toxins, bait, rubbish, medications, chemicals nor anything else that could have been scavenged.- Current vaccination status: not discussed- Current medications: nil mentionedTRIAGE:- HR: 130 bpm- Mm: Pink- Crt: <2 seconds- Temp: 38.3°C- Mentation: BAREXAMINATION:Body Condition Score:Pain Scale (0-4):Cardiovascular: A grade three out of six heart murmur was auscultated. Normal rhythm, pulse pressures normal and synchronous.Respiratory: Thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal discharge.Neurological: Neurologically no significant findings, no cranial nerve or proprioceptive deficits/gait, full neurological exam not performed.Musculoskeletal: Ambulating normally, no apparent neck, spine, limb or joint pain, full musculoskeletal exam not performed.Gastrointestinal:- Oral: NSF- Abdominal: NSF- Rectal: not performedUrinary: NSFReproductive (incl ext genitalia): NSFIntegumentary system: On the left aspect of the rump, approximately 3 cm from the base of the tail, there is a lesion with multiple rupture points and ongoing purulent discharge. A soft tissue swelling of approximately two to three centimetres in diameter surrounds the rupture site.Lymph Nodes: WNL on palpationEyes: NSFDIAGNOSTICS: Nil performedPROBLEM LIST:1. Ruptured abscess or cystic structure2. Grade three out of six heart murmurDIFFERENTIAL DIAGNOSIS: Ruptured abscess, ruptured infected cyst (e.g., sebaceous cyst), foreign body reaction.ASSESSMENT: Loki presented for a ruptured abscess on his rump. An underlying cystic structure is suspected. Supportive management was provided this evening. However, full resolution will likely require surgical excision of the lesion. Histopathology of the excised tissue may be beneficial for definitive diagnosis.TREATMENT:Buprenorphine 0.02 mg/kg was administered intramuscularly.The wound was clipped and cleaned. The wound was flushed with dilute chlorhexidine and sterile saline to debride the purulent discharge.PLAN:- Discharge into the owner's care.- Revisit with the primary care veterinarian is recommended to discuss surgical management options for the lesion.DISCHARGE INSTRUCTIONSPlease read through the following instructions to help guide your pet’s recovery. Do not hesitate to contact us at any time if you have any concerns or questions, and please let your vet or our client care team know if you have any questions about this information before you take your pet home today. Treatment summary: - Loki has been assessed for an burst cyst or abscess- The area was clipped and cleaned and he has been given pain relief- Please continue his pain relief and antibiotics at home.- A surgical consultation with your primary care veterinarian is recommended for long term resolution. Exercise:- Please follow the instruction of your veterinarian with regards to reintroduction of exercise.- If no specific instructions have been provided please keep your pet rested for the next 3 days then gradually reintroduce normal activity.Diet:- If your pet has suffered any gastrointestinal upset (vomiting or diarrhoea) please feed your pet bland food with no access to high fat foods or scraps. We recommend either a low fat commercial diet or boiled, skinless chicken with rice. Continue this diet for 3 days and then slowly reintroduce normal food. Recheck:- Please organise a recheck for your pet with your primary care veterinarian in THREE days to assess your pet's improvement unless otherwise advised by your veterinarian.Medications at discharge:Amoxyclav 500mg tablets:  Give ONE tablet by mouth, TWICE daily until finished. Meloxicam 1.5mg/ml: Give 1.5ml by mouth, ONCE daily WITH FOOD. Stop medication and seek veterinary attention if vomiting, diarrhoea or anoerxia occurs. If your pet’s condition is not improving or if other problems develop, please call your primary care veterinarian or if it is outside their normal working hours, please call Perth Vet Emergency.  We are open from 6pm until 8am Monday to Friday and 24h over weekends and public holidays. Phone 1300 040 400    Vital Signs