C09977323 / invoice 10000

HISTORY:Presented for castration; booking was intended for a different clinic.Widespread skin inflammation identified on presentation.Current meds: noneVaccination: Not mentionedParasite Prevention: Not mentionedPre-existing conditions: noneEXAMINATION:Eyes: Periorbital inflammation.Ears: No discharge, no inflammationNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painIntegument: Widespread inflammation noted, affecting the periorbital region, feet, chest, and scrotum.Reproductive: Scrotal inflammation. Large, pendulous scrotum.PROBLEM LIST:Widespread dermatitis (periorbital, pododermatitis, chest, scrotum)Large, pendulous scrotumIntact maleDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Widespread dermatitisDIAGNOSTICS:NoneASSESSMENT:Presented for castration but has significant, widespread dermatitis that requires management prior to any surgical procedure to minimise risk of post-operative infection.The scrotum is large and pendulous, making a scrotal ablation advisable at the time of castration to prevent future complications.TREATMENT:Cytopoint 40mg given subcutaneously.PLAN:Postpone castration until dermatitis is controlled.Recheck and probable admission scheduled for 17/03/2026.If skin remains inflamed at recheck, consider medical management with steroids and/or antibiotics.Plan to perform castration with concurrent scrotal ablation once skin condition has resolved.CLIENT COMMUNICATION:Discussed examination findings with the owner. Advised that proceeding with castration today is not recommended due to the severe skin inflammation and the high risk of surgical site infection. Recommended managing the skin condition first. Also recommended a scrotal ablation be performed at the same time as castration due to the large, pendulous nature of the scrotum, which could lead to post-operative swelling and other complications. The plan to postpone surgery and re-evaluate in two weeks was agreed upon.    Vital Signs