C09970137 / invoice 10000

Reason: Sore BottomConsultation Time: 28/02/2026 13:11History:Dobby presented for investigation of perianal irritation and licking, which has been ongoing for approximately four weeks. The behaviour started about a week before 19/02/2026. He was taken to Green Cross Vets where an attempt was made to express his anal glands, but nothing was expressed. Some firm faeces were manually removed at that time as he had been constipated for two days. Since then, he has been defecating daily, including this morning. The owner reports he frequently stops to lick at his hind end, sometimes for up to 30 seconds at a time, and this happens multiple times a day. He has also been observed scooting on various surfaces.His appetite and drinking are reported as normal. He is fed Hills dental diet. The owner is concerned about the persistent irritation and has also noted a weight loss of approximately one kilogram over the past six months, from 6.5 kilograms to 5.5 kilograms, despite a consistent food intake. He is up to date with Nexgard Spectra. The owner changed his diet from Blackhawk dry food to Hills dental diet 6 months ago but has been feeding 1/2 a cup of each and not been weighing the food.Subjective:Bright, alert, and responsive. Objective:Temp: 37.6  MM: Pink  CRT: <2s HR: 96  FP: SSWt: 5.5 kg BCS: 4/9CV:  No murmur or arrhythmiaRESP: Normal BV sounds, no nasal discharge, normal respiratory effortGIT: Comfortable on abdominal palpation. Rectal examination revealed the presence of a small amount of dry faeces in the rectum, despite having defecated earlier today. Anal tone was tight. No other abnormalities were palpated.U/G: No preputial dischargeNeuro: Appropriate mentationM/S: AmbulatoryInteg: The perianal skin is erythematous and inflamed, consistent with self-trauma from licking and scooting. There are no open wounds or signs of secondary infection. The rest of the haircoat and skin appear normal. No evidence of licking or itching on other body parts.Ophth: Pupils equal and appropriateLNs: Palpably normalProblem List:- Perianal pruritus and inflammation (four weeks duration)- Weight loss (one kilogram over six months)- Dry faeces and incomplete rectal emptyingAssessment:The primary presenting problem is chronic perianal irritation. The cause is unclear, but differential diagnoses include anal sac discomfort (despite previous unsuccessful expression), dehydration leading to firmer stools, or a primary allergic skin disease with an unusual distribution. The weight loss is also a significant concern, which may be due to underfeeding following a diet change six months ago, or it could be related to an undiagnosed systemic issue such as chronic kidney disease.Trial a laxative to help with increased stool defaecation, and short steroid course to address the inflammation at the perineum.Recommend a blood test in 3-4 days during the regular vet recheck.Feed 135g of hills dental diet divided into two meals (checked the recommended feeding guide on the bag).Increase water sources such as tuna in springwater or dog wet food. Treatment:- Dexamethasone 0.1mg/kg SC  - home with prednisolone 2.5mg PO SID for 5d-Lactulose 2.5ml PO BID for 4 daysE collar to prevent lickingPlan:Diagnostic plan:- Recommended a follow-up blood test with the regular veterinarian next week to investigate the weight loss and screen for underlying systemic disease, such as renal or liver disease, especially given his age.- Calculate the correct daily feeding amount for Hills dental diet.Therapeutic plan:- Dispense a short course of oral steroids to be administered once daily to manage the perianal inflammation and itch.- Dispense a laxative for three days to soften the stool and promote complete bowel evacuation.- An Elizabethan collar is to be used for the next few days to prevent further self-trauma.- Advised on dietary management to increase moisture intake.Discharge plan:- Re-evaluation recommended with the regular veterinarian at Green Cross Vets next week (Wednesday or Thursday) to assess response to treatment and to perform blood tests.Client Communication:Discussed the findings and the multifactorial nature of the presentation with the owner. Explained the plan to address both the skin irritation and the gastrointestinal signs concurrently, while also investigating the weight loss. Discussed the rationale for steroid and laxative use, and the importance of the follow-up blood test to rule out more serious underlying conditions. Consent was obtained for the treatment plan.    Vital Signs