C10008146 / invoice 10000

medical history emailed to ARH - AC 

Reason: Possible Cat fight 

Owner reports:
- may have got into a cat fight 
- came into home a few days ago with knock on head
- scratched head and from a little swell to side of face 
- pus not bleeding 
- does not seem bothered but eye is closed 
- EDDU wnl 
- no v+ d+ coughing sneezing 
- Diet: Kibble 
- indoors outdoors 
- Current meds: Metacam 0.2ml last night with food 
- utd with flea tick worming revolution 
- no other concerns 

Physical Examination:
BAR lovely but may be anxious pawsy 
BCS 4-5/9 
HR 188 no murmur or arrthymia 
RR sniffing clear lung sounds 
Pink mm crt <2sec 
DS 2/4 mod tartar 
All palpable lymph nodes normal 
Abdominal palpation a little tense 
Left eye closed, has marked inflammation, unable to open eye with topical LA as swollen. 
Scabbing wounds present on head, abdominal region 
No pus at the moment
Mild swelling on left side
Ears normal 
Right eye normal 
Temp 38.8

Assessment/Client communication:
1. Discussed cat fight/bite abscesses are a concern, unable to feel an abscess at the moment but can develop as it has been a few days since cat fight and left head area is mildly swollen. Recommended to start antiinflammatory and pain relief + antibiotics + relaxation. Owner opted for all except relaxation.
2. Recommended keeping indoors for the week but owner may only manage 3 days. 
3. Discussed if more swelling and not improving with treatment to return for vet recheck or go to emergency over the weekend if concerned 
4. Discussed if develops into an abscess will need flushing that will be under GA. Owner has been through something similar with other cat and understands the process. 
5. Discussed concern about corneal ulcer if was in a fight, owner did not notice any scratches in eye 
6. Discussed weight loss. 

Treatment:
1. Amethocaine in left eye but not improvement to visualise or check eye 

Plan:
1. Owner to start medication:
- Metacam Cat 3ml Oral [Pain relief] Give to 4kg dose with food, ONCE daily. Start 7 March for 5 days. Stop medication if any vomiting or diarrhoea and call vet.
- Rilexine Tabs 75mg [Antibiotics] Give ONE tablet by mouth morning and night. (every 12 hours). Start 7 March for 10 days.  
2. Send history to ARH (owner's preferred emergency centre) just in case needs to be seen over the weekend.
3. Recheck on Tuesday to see if swelling has decreased +/- blood test +/- check for abscess/eye lesion if present +/- extend medications if needed. 

Reason: vaccination

History:
Cat has been EDDU normally. No V+ or D+. Fed adult dry. Due for vaccination and worming. Multicat household. Indoors/outdoors.

Examination:
Vitals all WNL (HR: 164, RR: 24, MM: pink, CRT: 1-2sec). NAD on PE.
Oral: 0/4 PD

Assessment:
Patient appears stable. Suitable for vaccination.

Treatment:
Feligen RCP (batch: 2435210, exp: 10/26) S.Q.

Plan:
Repeat F3 vaccination in December 2026
Owner to arrange G.I. parasite prevention as soon as practicable.