C10008232 / invoice 10000

HISTORY:Galileo presented for acute onset of submandibular swelling and inappetence. The owner found him lying in the grass this afternoon, which is unusual behaviour. The swelling was noted at approximately 1:30 PM today and was initially larger, described as the size of a grape under his chin. It has since mostly resolved since being in the clinic.He has not eaten a full meal since last night but did consume some treats a few hours after initially refusing food this morning. At home, he was observed making licking noises without protruding his tongue and appeared painful when the owner tried to examine his mouth. He was panting with his mouth open during the car ride, but this has since resolved. There is no known history of a fight or access to toxins, although an insect bite or allergic reaction is considered possible by the owner. He has a history of being a nervous cat.EXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 2/4Hydration status (%): hydration clinically adequateCardiovascular: HR 220bpm, cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: Left-sided nasal discharge noted. Increased respiratory noise referable to the left nostril, consistent with a blockage. Thoracic auscultation clear sounds bilaterally, respiratory effort normal.Neurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint pain, full MSk not performedGastrointestinal: - Oral: Fractured right maxillary canine tooth (404) with the root still in visible. Query whether mild swelling remaining around chin but non palpable.- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: Anxious and nervous but allowed examination.PROBLEM LIST:- Submandibular swelling (resolving)- Inappetence- Fractured right maxillary canine tooth- Left-sided nasal discharge and stertor- Anxious temperamentDIFFERENTIAL DIAGNOSIS/DIAGNOSIS:- Tooth root abscess secondary to fractured canine- Allergic reaction (e.g., insect bite)- Other orodental disease/infectionDIAGNOSTICS:NoneASSESSMENT:Galileo presented for acute submandibular swelling and inappetence. Examination revealed a fractured right maxillary canine tooth and left-sided nasal discharge. The submandibular swelling has partially resolved and no discrete mass was palpable. The clinical signs are suspicious for a tooth root abscess secondary to the fractured tooth, though an allergic reaction cannot be completely ruled out. ]Further investigation under general anaesthesia, including dental examination, radiography, and bloodwork, is recommended.TREATMENT:Please refer to in clinic software e.g., smartflow for admitted patients.- Buprenorphine (oral) 0.26mL up to three times a day for pain relief.- Clavulox oral suspension, 1mL twice a day for 7 days.PLAN:Home into owner's care.The owner will need to reconstitute the Clavulox powder with 14mL of water and keep it refrigerated.Advised to monitor for appetite, activity, and recurrence of swelling.Strongly recommended to book an appointment with his regular veterinarian as soon as possible for a dental examination and treatment under general anaesthesia. Pre-anaesthetic blood testing was also advised.CLIENT COMMUNICATION:Discussed the examination findings, including the fractured tooth and nasal discharge. The primary concern is a likely tooth root abscess. The possibility of an allergic reaction was also discussed. Explained the treatment plan, including how to administer the oral pain relief and antibiotic suspension. Emphasised the need for a follow-up appointment with his regular veterinarian for a dental procedure to address the fractured tooth, which is the likely underlying cause of his signs. The owner was advised that a pre-anaesthetic consultation and blood tests would likely be required. The process for sedation was discussed, and the owner opted for medical management pending a visit to their regular vet. Advised to call if there are any concerns.    Vital Signs