C10016665 / invoice 10000

Weight (Kg):4.76
History:HISTORY:
O reports a lesion on the dorsum noted approximately two weeks ago. The patient has been licking the area. EDDU normal. No v/d/c/s. Normal energy levels.
Current medication: n/a
Parasite control: utd
Environment: Indoor only, lives with another cat. They have occasional altercations. No recent changes to diet or home environment.

EXAMINATION:
BAR
Cardio: no murmurs or arrythmias auscultated, both pulses strong and synchronous
Resp: normal respiratory rate and effort, no crackles/wheezes auscultated across all 4 lung fields
MMS: pink moist CRT 1.5s
Abdomen: comfortable, no mass effect or organomegaly palpated
LNs: PLNs WNL
Integument: Area on dorsum shaved to reveal a superficial graze-like wound. Evidence of self-trauma from licking. No evidence of fleas/ectoparasites.


ASSESSMENT:
Superficial pyoderma secondary to a suspected traumatic wound, exacerbated by licking.

PLAN:
-Wound was shaved and cleaned.
-Tape cytology performed, revealed bacteria.
-Prescribed 13mg/kg BID amoxyclav for 7 days.
-Prescribed oral meloxicam (0.4mL PO SID) for 3 days with food.
-E-collar placed to prevent further self-trauma.
-Discussed medication administration and to monitor for any GI upset.
-Advised monitoring interactions with the other cat at home.

COMMUNICATION:
O happy with above plan.

EC