C09994514 / invoice 10000

06/03/2026 Reason: Wound on ear

History:
2 weeks ago saw Chimi bite Hinas ear. Since then it never really fully healed. Would scab and then bleed again, O suspects Chimi may be licking at her wound/trying to groom it
Eye has cleared up very well with ocuflox, has worked the best out of other eye medications in the past, O would like to make note. Eyes still produce gunk and O has been cleaning with warm water, no redness or irritation
Hina herself doesn't seem to be bothered by her wound but O can't guarantee she is not also scratching at it
Also noted a bit of fur loss on her back paws likely from altercation with Chimi
Has feliway at home and uses zylkene occasionally but doesn't seem to work very well. Chimi is friendly with Hina but will suddenly change his mind unsure what the trigger is (could be he wants to be left alone sometimes and Hina doesnt get the hint, or if he is jealous as Hina is more smoochy)

Vital Signs:
Temperature:  not taken
Heart Rate: 172  bpm 
Pulse rate:  172
Pulse character: strong and synchronous. 
Respiration Rate: 40. 
MM: pink, moist
CRT: <1 sec

Dehydration assessment: Euhydrated MM moist no skin tent

PHYSICAL EXAMINATION:
Appearance: BAR; BCS 5/9
Eyes: nad. no redness, discharge, blepharospasm. responds to visual stimulus
Ears: R ear external pinnae moist shallow wound approx 0.4cm diameter, dry scab surrounding, mild erythema surrounding; L ear nad
Nose: nad
Oral Cavity: nad. no gingivitis, calculus/tartar or other oral lesion 
Cardiovascular: Auscultation no murmur detected ,pulse quality normal ,rhythm regular
Respiratory: RE normal , auscultation normal
Abdomen: soft and comfortable
Musculoskeletal: ambulatory all 4 limbs
Neurological: appropriate mentation
Integument: 2x alopecic patch on dorsal aspect of digit 1 and 2 LHL, approx 0.3cm in diameter each, no erythema
Peripheral LNs:Normal size, symmetrical
Urogenital: not assessed
Rectal exam: not examined

Assessment/Problem List:
1. Wound
DDx: fight with Chimi most likely +/- secondary infection (vs. underlying allergy if fight was not witnessed)

Treatment:
O unable to tablet at home
0.3ml cefovecin sc
Wound cleaned with dilute chlorhex, applied bacticorten and demonstrated

Plan:
Keep wound clean at home with dilute chlorhex BID, then applying bacticorten x7d
O has cone at home, ideally to keep on when not supervised even though Hina hates it
Discussed behaviour consult with Chimi/at home with Hina and Chimi

Recheck INI