C09982670 / invoice 10000

Appointment Notes: Overdue remindersHISTORY:Presents for the second episode of a skin lesion on the tail. The previous episode spread to the abdomen. Currently, the owner has noticed Toastie nibbling at the tail and the issue appears localised to the tail. The owner is concerned about a possible allergy. Eating and drinking normally. Otherwise bright and alert at home. Approx 2-3 years old.Current meds: noneProphylaxis: not discussedPre-existing conditions: noneAccess to toxins eg. Rodenticide: noneTRIAGE:HR: 140 bpmRR: NADTemp: 40.6 degrees celciusMm: pink and moistCrt: <2Mentation: BAREXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, no murmur detected, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: normal mentation, cranial nerves intact, ambulating well with no CP deficitsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:Oral: normal, no mouth pain, dental score (1-4): 1/4Abdominal: no detectable pain or organomegaly on abdominal palpation, normal gut soundsRectal: Not performed.Urinary: NSFReproductive: NSFIntegument/Ears: Moist dermatitis lesion on the underside of the tail base. Remainder of integument and ears are free of overt discharge or ectoparasites.Lymph Nodes: peripheral lymph nodes palpate within normal range.Eyes: Bilaterally clear with no dischargePROBLEM LIST:PyrexiaMoist dermatitis (hot spot) on tailDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Acute moist dermatitis (hot spot) secondary to suspected self-trauma vs underlying allergy.DIAGNOSTICS:NoneASSESSMENT:Toastie presented for a recurrent skin lesion on his tail. On examination, he is pyrexic (40.6C) with a focal area of acute moist dermatitis ("hot spot") on his tail, consistent with the owner's report of nibbling. The rest of the physical exam was unremarkable. The primary concern is the hot spot, with the pyrexia likely secondary to the skin infection/inflammation.TREATMENT:The patient will be sedated to facilitate wound management. Sedation protocol will be medetomidine and  methadone. The area on the tail will be clipped and cleaned. Will commence oral antibiotics and anti-inflammatories.PLAN:Admit for sedation, clip and clean of the tail lesion.Discharge home into owner's care with oral antibiotics and anti-inflammatories once recovered from sedation.Re-evaluation if not improving or if any new concerns arise.Amoxiclav: 1000mg BID for 7 days Metacam: 0.1mg/kg SID for 3 days large cone dispensed CLIENT COMMUNICATION:Discussed findings with the owner, Evie. Explained the diagnosis of a "hot spot" and the likely secondary pyrexia. Discussed the need for sedation to properly and comfortably treat the area, due to irritation. Quoted approximately $100 for sedation and $120 for the wound clip and clean, plus medications. The owner is comfortable to proceed and understands costs. Owners have pet insurance (Medibank) and a gap-only claim will be processed. The owners will leave for approximately 30-60 minutes while the procedure is performed.--- 03/03/2026 07:04:37 AM PED:Treatment - Resolved -    Vital Signs