C10002667 / invoice 10000

Reason: Dog AttackHISTORY:Banjo presented for assessment of wounds sustained after a Rottweiler reportedly broke into the owner's backyard earlier today. The owner was not home at the time but was alerted by a neighbour. The owner's mother attended approximately 15 minutes after the incident and did not notice any abnormalities. Tonight, the owner discovered the wounds while patting Banjo. He flinched when his ears were touched, and on inspection, two marks were found inside one ear and another mark on the top of his head. A small amount of blood was noted. The owner applied some Betadine to the wounds prior to presentation. Since the incident, Banjo has eaten his dinner, had a drink, and been for two walks. His companion, Blossy, appears to be unaffected.Diet consists of raw chicken and prime100 rollCurrent meds: noneProphylaxis: UTDPre-existing conditions: Owner reports a history of hypersalivation, particularly in the car.Access to toxins eg. Rodenticide:noneTRIAGE:HR: 160 bpmRR: 34 brpmTemp: 39.3°CMm: pinkCrt: <2 secondsMentation: QAR, anxious, hypersalivating EXAMINATION:Body Condition Score: 6/9Pain Scale (0-4): 3/4 (very painful on palpation of wounds)Hydration 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 findings, no cranial nerve or proprioceptive deficits/gait, full neurological exam not performedMusculoskeletal: ambulating normally, no apparent neck, spine, limb or joint pain, full musculoskeletal exam not performedGastrointestinal:- Oral: hypersalivating- Abdominal: no detectable pain on abdominal palpation, normal gut sounds- Rectal: not performedUrinary: NSFReproductive (incl ext genitalia): NSFIntegument/Ears: Multiple superficial wounds noted. Two 0.5 mm scratches on the inner left pinna, a wound on the outer left pinna, a wound on the central caudal forehead, and a wound on the inner right pinna. The wounds appear to be superficial scratches rather than deep puncture wounds. The surrounding areas were clipped and cleaned. No other wounds were found on full body check. Blossy, the companion dog, was also checked by O in consult and no abnormalities were found.Lymph Nodes: WNL on palpationEyes: NSFPROBLEM LIST:- Multiple superficial bite wounds/scratches (head and ears)- Pain- Anxiety- HypersalivationDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Superficial bite wounds/scratches secondary to dog attack.DIAGNOSTICS:All wounds were clipped and cleaned using chlorexidine water.ASSESSMENT:Banjo presented for assessment following a reported altercation with a Rottweiler. Examination revealed multiple superficial scratches and minor wounds on his head and ears, which were very painful on palpation. No deep puncture wounds were identified. The wounds were clipped and cleaned. Given the superficial nature of the injuries, it is thought the incident was likely related to rough play rather than a direct aggressive attack. Treatment was initiated to manage pain and prevent secondary bacterial infection.TREATMENT:- 0.3mg/kg Methadone administered IM at 8:45 PM for analgesia prior to clip and clean.- Wounds clipped and cleaned.- Neocort topical cream applied to all wounds.- 0.2mg/kg Meloxicam SC- Amoxyclav 312.5mg BID until finishedPLAN:- Discharge with a 5-day course of oral Amoxiclav to be administered twice daily to prevent infection.- A cone has been provided to prevent self-trauma (scratching) to the wounds. It is recommended he wears this when unsupervised.- Advised the owner to feed cooked chicken breast instead of raw chicken ideally- No further pain relief or anti-inflammatory medication to go home with at this stage as the wounds are superficial.CLIENT COMMUNICATION:Discussed the findings with the owner, explaining that the wounds were superficial and appeared to be scratches rather than deep bites, suggesting the interaction may have been rough play. Explained the treatment provided in hospital, including pain relief, antibiotics, and wound cleaning.Discussed the plan for home care, including the course of oral antibiotics and the importance of using the cone to prevent self-trauma. Advised on feeding cooked chicken during the antibiotic course. Advised the owner to monitor the wounds and to seek further veterinary care if there is any swelling, discharge, or if Banjo seems unwell.    Vital Signs