C09989265 / invoice 10000

Appointment Notes: Puncture wound-EMERGENCY CONSULTHISTORYPresenting for: Feline patient  presented for evaluation of abnormal gait and suspected bite wound/fight injury. Client noticed patient was not acting right this morning and observed abnormal gait/movement this afternoon.Lifestyle Risk Factors:- Primarily indoor cat; outdoor access possible but limited - client states other cats are rarely seen entering the property during daytime- Neighbouring male cat (across the road) previously known to visit and was friendly with patient; that cat reportedly became reluctant to return after being accidentally locked in overnight with patient on a prior occasion - no altercation was noted during that incident- Possum exposure considered possibleEXAMWt: 6.57 kgT: Not TakenIntegumentary: Single puncture/bite wound identified on one side of the body (specific anatomical location not documented). No other wounds identified on full body search. No dry blood noted around wound. Wound assessed as approximately 24 hours old based on appearance (not fresh). Wound probed - did not penetrate into the abdominal cavity.Musculoskeletal: Abnormal gait observed by client at home; stiff movement noted on presentation consistent with pain from wound site.ASSESSMENTSuspected bite wound/puncture injury - approximately 24 hours old; single wound identified on body wall. Probing did not indicate abdominal penetration or peritoneal involvement. Bruising/subcutaneous injury beneath the head/neck region cannot be excluded given mechanism. Abscess formation is a risk given wound age and aetiology.PLANNew Meds/Tx:- Antibiotics - Meloxicam (pain relief): to be administered at home tonight with food. Continue for 2-3 days. Client instructed to retain remaining medication and not discard it.Additional Discussion:- Wound probed and assessed - no evidence of abdominal penetration. Claw penetration into the abdomen causing peritonitis was considered; this has been ruled out clinically at this time but would require surgical intervention (wound flushing and closure) if it were the case.- Abscess formation remains a risk - antibiotics prescribed as prophylaxis/treatment.- Patient should improve with pain relief once administered tonight with dinner.Client Comms:- Administer Meloxicam with food tonight; continue for 2-3 days. Do not discard remaining medication.- Complete full 5-day course of antibiotics (2 tablets BID).- Monitor for signs of abscess development or deterioration.- Return if condition worsens or abscess develops.    Vital Signs    Weight: 6.7;       MMColour: Pink;       HeadEyes: Normal;       Nose: Normal;       Skin: Abnormal (Wound to right side of body/abdomen; does not rpobe into the abdomen);       MusculoSkeletal: Normal;       Ears: Normal;       Neck: Normal;       LymphNodes: Normal;       Heart: Normal;       Lungs: Normal;       Abdomen: Normal;       RectalGenetalia: Normal;       Temperature: 36.5;       BodyScore: 5;       HeartRate: 188;       RespirationRate: 12;       CRT: 1-2;