C09972285 / invoice 10000

Hx: Gained some weight - eating cat food! loves the hypoallergenic. 
EDDU normal, nil v+/d+
Itchy skin in inguinal area and some matting, scooting her bottom. 
Nil change to diet apart from cat food... 

Exam:
BAR, lovely boy!!! BCS 7/9... 
EENT: MM P <2s, G2/4 dental disease on caudal teeth only. 
CVS: HR 100bpm, clear ausc, ssfp
Resp: clear ausc normal effort
Abdo palp: soft and comfrotable nil organomegaly noted. 
Integument: erythema to inguinal skin, matting in fur surrounding. 
Rectal: AGs expressed bilateral full but easy to express. Some erythema around bottom. T not taken. 
Neuro: normal gait and mentation
MSK: ambulatory x4
Urogenital: nad. 

Assessment:
Fit to vaccinate
Itchy - secondary to matting or change in diet? vs atopy

Plan:
Trial topicals first (malaseb once weekly for 3 weeks) follow with conditioner. If not improving may need to consider oral medications (JAK inhibitors, pred) 
Recommend dental procedure in next few months. 

H: A few issues:
1 - Bad breath, but no longer present? Now only eating dog food instead of human snacks. 
2 - Nail trim?
O noted he was already anxious and reluctant to go into the clinic.
EDUF normal. Lives with 2y spaniel.
Due for vaccinations now.
Diet - Optimum dry
P/c - UTD

O: BAR, good boy, warms up - likes treats
MM pink CRT <2s
EENO NAD
HR normal, no m/a
Chest clear
Abdo palp comfortable
Teeth mild calculus and gingivitis
Coat - a few small matts esp on medial thighs
BCS 6-7/9 
Muscle 2/2

A: Healthy for vaccination
Grade 2 dental dz
Overweight

P: Vaccination duramune c5 s/c
Nails checked - long quicks and nails themselves not too long. LF dew claw trimmed (only long nail)
Discussed dental health - recommend daily brushing, dental scale and polish in next 6-12m
Recommend weight loss, aim for 25kg as starting point