C10020600 / invoice 10000

Reason: May Have Developed AbcessHistory-Update:History:Facial swelling and grimacing noted, initially suspected bee sting but now purulent discharge visiblePuncture wound observed on lip exterior with associated bleedingSwelling predominantly right-sided facial region with malodorous dischargeRecent bone chewing activity prior to symptom onsetPrevious vaccination appointment scheduledExamination:Behaviour: BAR, NADCardiovascular: NAD. Pink moist MM CRT <2 and no murmurs detectedRespiratory: NAD, normal effort and bronchovesicular soundsGIT: comfortable, pliable, no mass effectsMusculoskeletal: No pain on palpation of any joint or long bone. Ambulatory 4x4Neurological: NADIntegumentary: NADLN: NADOral Cavity: Purulent discharge visible, puncture wound on lip exterior with bleedingOcular: NADAural: NADUrogenital: NADTemperature: 39.0°C (elevated but not febrile)Assessment:Facial swelling with purulent discharge, likely foreign body or penetrating injuryPossible stick or bone fragment embedded in oral tissuesPlan:Empirical antibiotic therapy commencedAnti-inflammatory medication prescribedSedation and exploration scheduled for tomorrow afternoonPossible general anaesthesia if required for thorough assessment and foreign body removalClient communication:Treatment plan discussed including sedation procedure tomorrowMedication administration instructions providedPre-anaesthetic fasting instructions given: dinner tonight permitted, water until morning, no food from morning of procedureAdvised to monitor response to medical therapy overnight    Vital Signs