C10019935 / invoice 10000

Weight (Kg):33.20
History:HISTORY:
O presented P for evaluation of a puncture wound on the dorsum, noted yesterday post-grooming. O cleaned the wound with salt water this morning. P is not licking the area.
EDDU normal. No v/d/c/s. Normal energy levels.
Current medication: n/a
Parasite control: O reports previously using a product from a supermarket but is not current.
Environment: Indoor, with access to a park and a neighboring construction site.

EXAMINATION:
BAR
Cardio: HR , 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
Dental grade
Eyes: clear, no discharge of inflammation
Nose: clear, no discharge or inflammation
Ears: clear, no discharge or inflammation
Abdomen: comfortable, no mass effect or organomegaly palpated
LNs: PLNs WNL
Integument: A clean, healing puncture wound was noted on the dorsum with some granulation tissue present. No signs of infection (erythema, purulent discharge, malodor). No evidence of fleas/ectoparasites.
MSK: ambulatory all 4 limbs, normal proprioception all 4 limbs, no pain noted
BCS: 5/9

ASSESSMENT:
- Dorsal puncture wound, non-infected.

PLAN:
- Wound cleaned with chlorhexidine solution in clinic.
- Dispensed 5-day course of NSAIDs.
- Dispensed chlorhexidine solution for daily cleaning for 3 days.
- Dispensed antiseptic wound gel for application 2-3 times daily.
- Dispensed Bravecto.
- Recheck if any signs of infection develop (redness, swelling, discharge, malodor).
- Vaccinations are due August 2026.

COMMUNICATION:
O happy with above plan. O was advised not to use leftover steroids from a previous condition as they can impair wound healing.

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