C09975190 / invoice 10000

Reason: Skin IrritationHistory:Last week during weekdays patient was licking at the bum, owner had a look and saw redness and sore skin on the area near his anus.Owner left him alone and seemed to get less itchy, however by weekend he started to lick himself again and even more vigorously, owner had another look and found redness and sore skin on the same patch but also on the tail base.Patient not really itchy anywhere else and not normally an itchy dogEDDU fineVDCS noneDiet royal canine dry, no recent changeEnvironment Indoor and outdoorOther pets noneParasite prevention Nexgard spectraMedicatiion/supplement noneMentation - BARBCS - 5/9MM - pink and moistCRT - <2sHR=PR=116, no murmur or arrhythmia auscultatedRR 36, no abnormal lung sounds auscultatedEars - external ear canals clearEyes - no discharge, pupils symm, sclera clearMouth - moderate amount of calculi, grade 1 periodontal diseaseLymph nodes - all palpable LNs of normal sizeIntegument - patch of semi-scabbed roughened skin with associated inflammatioin present on skin right lateral to anus and on ventral aspect of tailAbdo - soft and doesn't elicit painMSK - ambulatory without lamenessRectal - both AGs slightly filled up but not particularly enlargedSticky tape cytology - large amount of neutrophils and small-moderate amount of intracellular cocci bacteriaAmoxyclav 125mg PO BID for 14 daysPrednisolone 5mg PO SID for 5 days 2.5mg PO SID for 10 daysAsked owner to also clean affected area with antiseptic (diluted betadine and chlorhexidine) twice daily for next 14 days, and bring him back if condition doesn't resolve    Vital Signs    Weight: 8.1;