C09983199 / invoice 10000

WEIGHT: 8.00
HISTORY: - Pruritus and licking around caudal region, particularly scrotum and perineal area
 - Onset following grooming appointment last Wednesday; groomer reported he became fractious during procedure
 - Large mat present in inguinal region prior to grooming; area has always been sensitive
 - Cone applied on Sunday; very stressed with cone, whining, keeping owner up at night
 - Home treatments attempted: antibiotic cream, cortisone cream (human formulation), aloe vera - no improvement
 - Able to refrain from licking when cone removed during walks with verbal correction
 - Faeces normal; initially reduced output but now normalising
 - Generally itchy dog but not keeping owner up at night prior to this episode
 - Desexed previously

Objective:
 - Scab present on caudal aspect of scrotum, likely secondary to licking
 - Abdomen non-painful on palpation
 - Anal glands: mildly full bilaterally, easy to express, not excessively impacted

Assessment & Plan:
1. Pruritus with secondary self-trauma
 - Likely residual irritation from matting and/or seasonal allergy flare-up
 - Corticosteroid injection administered today; should last until Saturday
 - Prednisolone 5mg tablets dispensed: one tablet once daily for two days from Saturday, then reduce to half tablet once daily if needed
 - Continue cortisone cream topically
 - Keep e-collar on for at least 24 hours while injection takes effect
 - Recheck if not improved within one week
 - Return if still pruritic by Friday for reassessment

WEIGHT: 8.60
HISTORY: Cyst under armpit L axilla
Hopping on back leg LHL when at beach. No issues at home 

EDDU normally for him
Good level of actiuvity 

E:
some matts 
L axilla - small fluid swelling. spray and clean, appears to be resolving 
LHL - unable to find abnormality. Even musculature patelela not luxating. Tense so difficult to move hip 
DG 0 
BSC 5
HR 128 - no audible 
Abdo palp nsf 


P:
update vaccination 

Clean wound/cyst with salty water and prevent licking - revixsit if no improvement seen
Rest for 7 days with slow intor back to activity. Next step sedation and radiographs 
No metacam as is fine if not at beach

HISTORY: Claim for 6/5 emailed to insurer ajs