C10032626 / invoice 10000

pet insurance
lethargic all day 
- face swollen 
- outside cat 
- wound little on head 
- 2 days

Reason: (BEAH consult)

PRESENTING/OWNERS CHIEF COMPLAINT/REASON FOR VISIT
Leo presented for facial swelling and a cut on his head. The owner noticed the swelling approximately 2 hours prior to the visit. The injury is suspected to be from a fight with another cat a couple of nights ago.

Consult Nurse
Diane

History
EDDU: Normal  
Vomiting/Diarrhea: No V+ or D+  
Diet:  
Vaccinations: Up to date  
Preventatives:
-   Worming:
-   Heartworm:
-   Flea & Tick:
Current Age:  
Current Medications:  
Behaviour Concerns: The owner reports Leo is a rescue cat and is generally wary of people, except for the owner's husband.  
History: Leo was presented for acute facial swelling and a wound on his head. The owner reports he was in a fight with a large white cat a few days prior. He is still eating and drinking normally. He is an indoor/outdoor cat who has been accessing the house through a window. He is insured with petinsurance.com.au.

Physical Exam
General Appearance: BAR  
Behaviour: Anxious and resentful of handling during the examination.  
Vitals: HR:180 ; RR:48 ; T: 40¡C; MMC: Pm ; CRT: 2sec  
Hydration: normal  
BCS: 5/9  
EENT: eyes clear, no evidence of conjunctivitis, no discharge or blephrospasm; no swelling or discharge to the external ear canal, ear pinnae clear; no nasal discharge; significant swelling over the nasal bridge secondary to a wound on the head. A fractured left upper canine tooth was noted (historical). Grade 1 dental disease
Cardiac: normal rate and rhythm, no murmurs on auscultation  
Resp: normal rate, normal clear sounds auscultated in all lung fields  
Abdo: comfortable on abdominal palpation, no palpable abnormalities  
Urogenital:  
Integument: A large cat bite abscess was identified on the top of the head. The area was clipped and cleaned, revealing a puncture wound from which a large amount of purulent discharge was expressed. The wound was flushed with 3 mL of saline. A second, smaller puncture wound was noted near the ear. Significant subcutaneous oedema and cellulitis are present over the face and nasal bridge, consistent with gravitational tracking of inflammation from the primary wound. no external parasites noted; no erythema or pruritis beyond the affected area.  
Neuro: proprioception NAD; NSF  
Musculoskeletal: ROM in all joints NAD; no abnormalities on palpation  
Lymph Nodes: Peripheral LN's WNL

Client Communication from Consult Nurse

Client Communication with Vet
I explained that the wound on Leo's head is a classic cat bite abscess. These occur when bacteria from a cat's tooth or nail are injected under the skin, leading to a significant infection and pus accumulation.  
I informed the owner that Leo has a very high fever of 40¡C, which is consistent with a significant infection.  
I discussed the treatment performed, which involved clipping the hair, cleaning the wound, and flushing out the pus and debris to allow it to drain.  
I reassured the owner that Leo's body weight (6.3 kg) and condition are ideal (BCS 5/9), explaining that the perception of him being "skinny" is often because many pet cats are overweight.  
The plan for medical management was discussed and accepted by the owner. This includes a long-acting antibiotic injection (to avoid the difficulty of tableting while her husband is away) and oral anti-inflammatory/pain relief medication to be given once daily.  
I demonstrated how to administer the oral liquid medication and advised on home care, including keeping the wound clean if Leo allows it.  
The risk of Feline Immunodeficiency Virus (FIV) transmission through cat fights was discussed. I advised that we should keep this in mind and consider testing and vaccination in the future.  
I explained that the facial swelling is due to gravity pulling the inflammation and fluid down from the head wound and that it should resolve as the infection is treated and the pressure is relieved.  
The owner was informed that we would attempt to process the insurance claim through GapOnly.

Assessment/Problem list
-   Cat bite abscess on the head
-   Pyrexia (fever)
-   Facial cellulitis/oedema secondary to abscess
-   Fractured left upper canine (historical)
-   At risk for FIV/FeLV due to fighting

Treatment
Medications:
-   Wound management: The abscess on the head was clipped, cleaned, and flushed extensively with sterile saline.
-   Convenia injection administered subcutaneously for long-acting antibiotic coverage, 0.65 mL SQ
-   Meloxicam 1.2 mL administered orally for pain relief and anti-inflammatory effects.

Plan
-   Administer Meloxicam oral suspension once daily as prescribed, 0.65 mL SID The next dose is due tomorrow evening.
-   Keep Leo indoors to prevent further fighting and allow the wound to heal.
-   Monitor for continued appetite, normal energy levels, and improvement in swelling.
-   The owner may gently clean the wound with a warm compress if tolerated.
-   Recheck immediately if he becomes lethargic, stops eating, or if the swelling worsens.
-   Consider FIV/FeLV testing at a future visit.
  
(GHC in 6mths)

Internal treatment plan Comms
-   Discussed case with Dr. Diane. Confirmed plan for a straightforward cat bite abscess.
-   Agreed on using Convenia (long-acting injectable antibiotic) due to owner's difficulty with administering oral medications, especially as her husband is away until the following night.


Follow up notes
Recheck call to assess response to treatment and check on wound healing.  
Follow up phone call for: 2 days

DJ

PRESENTING/OWNERS CHIEF COMPLAINT/REASON FOR VISIT
Quilpie: Annual C5 vaccination and ProHeart SR-12 injection.  
Leo: General health check and dispensing of parasite preventatives.

Consult Nurse
Maddie

History

Leo (5-year, 3-month-old MN Domestic Shorthair)  
EDDU: Normal  
Vomiting/Diarrhea: No V+ or D+  
Diet: Hill's Science Diet and Royal Canin  
Vaccinations: F3 vaccination due 28/07/2026.  
Preventatives:
-   Worming: Due for tapewormer.
-   Heartworm/Flea & Tick: Bravecto Plus, due now.
Current Age: 5 years, 3 months  
Current Medications: Uses a dental powder supplement on food.  
Behaviour Concerns: Tends to be a 'one-person' cat and avoids other family members.  
History: No significant previous medical history noted.

Physical Exam
Leo  
General Appearance: BAR; Bright and alert.  
Behaviour: Initially calm, became fractious for pilling.  
Vitals: HR: 168 bpm; RR: ; T: 38.0¡C; MMC:pink ; CRT: <2  
Hydration: normal  
BCS: 7/9 (Weight 6.3 kg)  
EENT: eyes clear, no evidence of conjunctivitis, no discharge or blephrospasm; no swelling or discharge to the external ear canal, ear pinnae clear; no nasal discharge; Fractured upper left canine tooth (204) noted. The tooth is discoloured (black), suggesting a chronic injury with pulp necrosis. Mild plaque and minor gingivitis present on other teeth.  
Cardiac: normal rate and rhythm, no murmurs on auscultation  
Resp: normal rate, normal clear sounds auscultated in all lung fields  
Abdo: comfortable on abdominal palpation, no palpable abnormalities  
Urogenital: male desexed  
Integument: no external parasites noted; no erythema or pruritis  
Neuro: proprioception NAD; NSF  
Musculoskeletal: ROM in all joints NAD; no abnormalities on palpation  
Lymph Nodes: Peripheral LN's WNL

Client Communication from Consult Nurse
Confirmed Leo was present for a general health check.  
Discussed updating parasite prevention for both pets today. The owner agreed this would be helpful.

Client Communication with Vet
The owner is organising all pet care ahead of her next round of treatment for blood cancer.  
  
Leo: Discussed the finding of a fractured and discoloured upper left canine tooth. Explained that it appears to be a chronic issue, but carries a risk of infection or abscess. Recommended monitoring for signs of oral pain (e.g., dropping food, facial rubbing). The plan is to perform dental x-rays at his next dental procedure to assess the tooth root. A pre-dental check in 3 months was recommended. The owner accepted this plan.  
  
The importance of maintaining strict parasite control for the pets was discussed, given the owner's health status.

Assessment/Problem list
Leo:
-   General health check.
-   Fractured upper left canine (204) with suspected pulp necrosis.
-   Mild gingivitis.
-   Due for parasite prevention.

Treatment
Leo (6.3 kg):
-   Tapeworm tablet administered in clinic.
-   Bravecto Plus for large cats (6.25-12.5 kg) applied topically.
-   Dispensed: Additional tapeworm tablets.

Plan
Leo:
-   Administer dispensed tapewormer as directed.
-   Monitor for signs of oral pain (dropping food, pawing at face, reduced appetite).
-   Return for a pre-dental check-up in approximately 3 months to re-evaluate the fractured tooth.
-   Return in July 2026 for annual F3 vaccination. Reminders will be set.

Internal treatment plan Comms (-)

Follow up notes
Quilpie: Set reminders for Bravecto and Drontal due 01/06/2026.  
Leo: Set reminders for Bravecto Plus due in 3 months and F3 vaccination due 28/07/2026.

PRESENTING/OWNERS CHIEF COMPLAINT/REASON FOR VISIT: (F3 Vaccination
in day care - o not present 
- noc 
- hills normal cat
- due for bravecto + tw too pls)

Consult Nurse: (KT)

History:
EDDU normal
No V+ or D+ (nil)
Diet: (Hills science)
Vaccinations: (F3 today)
Preventatives; 
Worming: (Tapewormer and Brvecto plus today)
Heartworm: (Brvecto plus today)
Flea & Tick: (Brvecto plus today)
Current Age: (4y9m)
Current Medications: (nil)
Behaviour Concerns: (nil)
History: (Clinically fit for vaccination)

Physical Exam:
BAR; (Y)
Behaviour: (Friednly)
HR: (200); RR: (sniffing);  T: (37.8); MMC: (pink); CRT: (<2s);
Hydration: normal
BCS: (4)/9
EENT: (eyes clear, no evidence of conjunctivitis, no discharge or blephrospasm); (no swelling or discharge to the ears)
(MILD DENTAL STAINING + GINGIVITIS)
Cardiac: (normal rate and rhythm, no murmurs on auscultation)
Resp: (normal rate, normal clear sounds auscultated in all lung fields)
Abdo: (comfortable on abdominal palpation, no palpable abnormalities)
Urogenital: (NAD - desexed)
Integument: (no external parasites noted; no erythema or pruritis)
Neuro: (proprioception NAD; NSF)
Musk: (ROM in all joints NAD; no abnormalities on palpation)
Ln's: (Peripheral LN's WNL)

Client Communication from Consult Nurse:
(-)

Client Communication with Vet:
(-Discussed mild staining and gingivitis on healthcheck form - recommended to start teeth brushing and plaque off)

Laboratory/Imaging:
(-)

Assessment/Problem list:
(Mild dental staining & gingivitis
Clinically fit for vaccination)

Treatment:
Medications: Drug name, mg/Kg or mg dose, volume/tablets given 
(Fel-O-Vax 3 (Batch:3254007) given SC midline neck
3x Praziquantel (virbac) tapewormer given PO in consult
Bravecto plus 6-12kg spot on applied on back of neck in consult)

Client Communication with Vet:
(-)

Plan:
(GHC in 6mths)

Internal treatment plan Comms:
(-)

Follow up notes:
(-)
Follow up phone called for for (-) days