C09971918 / invoice 10000

Reason:Suspect hotspot on tailHistory:Swimming in river approximately one week ago with suspected tail injury during that time. Over past few days tail appears sore with continuous licking. Owner noticed oozing and bleeding around mid portion of tail today.Subjective:BARObjective:TPR: WNL, MM: pink and moist, CRT: < 2sec, <5% dehydrated..Cardiovascular: No heart murmur, regular rhythm, strong synchronous pulsesPulmonary: Normal lung sound and effort.Abdomen: Soft and non-painful.Musculoskeletal: Ambulatory x4 with no obvious lameness.Integument: Superficial dermatitis wound on ventral and dorsal aspects of tail following clipping and cleaning with diluted chlorhexidine. Ventral aspect appears slightly worse than dorsal aspect.Neurologic: Alert and appropriate, cranial nerves intact, normal gait. no neuro deficits on PE.Assessment:Superficial infection of probable hotspot with continuous licking behaviourPlan:- Clipping and cleaning of the tail- Metacam for pain relief- Cephalexin 500mg by mouth twice daily for one week- E-collar to remain on for seven to ten days- Reassessment by regular vet in three to five daysClient Communication:Discussed concern for possible superficial infection of probable hotspot, particularly with continuous licking behaviour. Advised on pain management with Metacam and antibiotic treatment with cephalexin. Emphasised importance of e-collar compliance for seven to ten days and arranged follow-up with regular vet in three to five days.    Vital Signs