C10000936 / invoice 10000

Reason: Irration On Face, Sore Mouth And Not Eating.Appointment Notes: wont let o check mouth, has irritation on face from pawing at it all night.    Vital Signs    

Reason: pawing at faceHistory: Started last night on RS of cheek first then at night started on the LS. Fur on the area became discoloured. Obsessive scratching and rubbing on the groundUTD with prevsExamination: BAR, very boisterousIntegument - discolouration on fur on lateral aspect of face bilaterally close to TMJ. Couldn't part the fur as too boisterous and area sensitive.Offered O to keep in hospital and give gaba 600mg + traz 200mg PO and try again later when calms down. O ok'd this.Gaba 600mg + traz 200mg PO given by AH. Re-examined 2 hours later, bit calmer, but when trying to examine affected area would thrash away. Muzzled.GY + 2 nurses held and was able to part fur on both sides of cheek to reveal ulcerated, moist lesion. No puncture wounds at all. Could not clip and clean, would not tolerateAssessment: Hot spot most likely Treatment: Metacam 2.5mg SID PO for 4 daysAmoxyclav 500mg BID PO for 7 days with foodE collar on at all timesConsent has been given by the client to proceed with this treatment  -  YesPlan:RC in 3-4 days when hot spot less painful for clipping and cleaning    Vital Signs    Weight: 23.8;       

Appointment Notes: Overdue remindersHistory: Examination: Laboratory: Assessment: Treatment: Consent has been given by the client to proceed with this treatment  -  Yes/No Plan:    Vital Signs    Weight: 22;