C10000307 / invoice 10000

Reason: Wound On Head Potential CfaAppointment Notes: Bad debtor, Overdue remindersHISTORY:  Presented for assessment of a wound sustained in a fight. The owner noticed the wound this morning. Yesterday, the patient was inappetent in the morning but ate in the evening. This is unusual. Normal bowel movements reported. A previous fight in 2024 reportedly led to gastrointestinal issues. Current meds: noneVaccination: Not mentionedParasite Prevention: Not mentionedPre-existing conditions: noneAccess to toxins eg. Rodenticide: none EXAMINATION:Body Condition Score: 5/9Pain 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): not graded- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: Puncture wound on head, Mucopurulent discharge noted, Small laceration on lateral edge on Lt ear pinna-Lymph Nodes: NSFEyes: NSFDemeanour/Behaviour: not discussed PROBLEM LIST:- CFA- Small cut on L ear pinna DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:- CFA DIAGNOSTICS:None ASSESSMENT:  Presented for an ear laceration from a fight. Examination revealed a small puncture on head. The wound was flushed. Small cut on L ear TREATMENT:  - The wound was flushed in consultation.- Tissue glue was applied to the cut on ear pinna.-Amoxycalv BID- The wound was left open to drain and prevent abscess formation. PLAN:- Home into owner's care.- Monitor for signs of abscess formation (e.g., significant swelling).- If an abscess develops, re-presentation will be required for drainage and potential drain placement. CLIENT COMMUNICATION:Discussed wound management, explaining the decision to leave the wound open to heal to prevent abscess formation. Advised on signs of abscess development (e.g., large swelling) and the need for re-evaluation if this occurs. Treatment would involve draining the abscess and possibly placing a surgical drain. Prognosis is good with early antibiotic intervention.    Vital Signs    Weight: 7;       HeartRate: 180;       DentalGrade: 2;       RespirationRate: 20;       CRT: <2;       MMColour: Pink;       Temperature: 39.1;       BodyScore: 8;