C09976848 / invoice 10000

Reason: Unwell - Droopy Eyes And LethargicAppointment Notes: Overdue remindersRegular Vet: Beach and Bay History:Presenting for now seeming right this afternoon. Archie had been out on relatives property , seemingly normal , O then went out and when they returned home, he appeared to be not quite right. O has recently moved and he has been escaping the yard. Relative mentioned today that he had a softer stool with corn in it - O has not fed him corn or had corn recently so assumed he has been scavenging. Not UTD on tick prevention. Examination:General demeanour:QARCardiovascular: HR 100, chest ausc clear, MM pink and moist, CRT <2s, pulses s+s, BP 148/96 (112)Respiratory: RR 36, normal REAbdomen: NAD, soft abd comfortableEyes: NADEars: NADOral exam: mild ulceration of gingiva near L maxillary carnassialPeripheral LNs: NADMusculoskeletal: pain on extension of L stifle, no notable swelling, instability or joint effusion, no palpable cranial drawer. Gait:Hunched stance, intermittent non weight bearing lameness in the LFL. Difficulty rising form being seated. Difficulty sitting also. Neurological: NADInitial Assessment:LHL lameness - soft tissue injury, CCL disease, bony injury D+ - dietary indiscretion likely. Initial Plan:Discussed sedated radiographs with O. O deciding on conservative management for now with pain relief and strict rest. Discussed if no improvement in 48-72 hours then strong recommended reconsidering radiographs. Discussed providing a bland food diet for the next 7 days and monitoring for progressive gastrointestinal signs. Treatment:Gabapentin 300mg PO BID x 7 days Paracetamol 250mg PO BID x 5-7 days Client communication:See d/c letter attached.    Vital Signs    Weight: 18;       

Reason: Skin InfectionAppointment Notes: Overdue remindersPresented and seen by Dr Corne Loots on 30/11/2025    Presenting Problem:Tail and peri-anal localised dermatitis (hot spot)History:Been camping at open water a couple of weeks ago. Last night didn't want to eat and is biting at his back side. Up to date on flea and tick.Any current medications:Had one dose of cephalexin yesterdayAny access to potential toxins?:NoE/D/U/D:No vomiting, one loose stool yesterday decreased appetite yesterday.Any known conditions:Pododermatitis about a month agoExamination Findings:General demeanour:QARTemperature:WNLCardiovascular:REgular no murmurRespiratory:Normal effort, panting, pain anxious.Oral exam:MM pink, especially over caninesAbdomen:NADPeripheral LNs:NADEyes/Ears:NADIntegument:Peri-scrotal and tail severe localised pruritic / purulent dermatitis.Musculoskeletal:Good muscle mass and toneGait:AmbulatoryNeurological:NADRectal exam:Not performedUrogenital:NADBody Condition Score:IdealInitial Assessment:Localised dermatitisClient Communication:Dear AlexArchie has a severe localised dermatitis / hot spot around the tail and scrotal area. There are signs of secondary bacterial infection. Please apply Neocort twice daily on the affected area.Please give Cephalexin 600mg, 1/2 a tablet twice daily with food for 10 days.ANTIBIOTICPlease give Pred X 20mg one tablet once daily for 3 days. STEROIDPlease give 250mg  Paracetamol / Panadol (1/2 of a 500mg tablet) twice daily for pain.Treatment:Clipped as much as Arhcie could tolerate, cleaned with chlorhexidine and applied Neocort. Cephalexin 20mg/kg bid for 10 days. Neocort on affected area bid and Pred 20 sid for 3 days. Paracetamol 250 mg bid.Plan:Revisit if not improving. Keep ecollar fitted    Vital Signs    Weight: 19.5;       MMColour: pink;       Temperature: 38.9;       HeartRate: 136;       BodyScore: 5;       DentalGrade: 1;       RespirationRate: panting;       PainScore: 2;       CRT: 1;       

Appointment Notes: Overdue reminders--- 16/11/2023 23:30:48 KMA:Brought in after having tick removed from over R eye. Around the eye was slightly swollen. Concerned about having left the head of tick in dogs eye - explained that may cause local irritation. Offered consult for swollen eye - O's declined, to take to RV in AM. UTD with Nexgard 2 weeks ago. Non-symptomatic, tick removed by O at home. Explained that we would not treat if asymptomatic. Gave O's a tick paralysis form to read through and to watch out for any signs that are listed. Bring straight back for a consultation if any signs start to show.    Vital Signs