C09986009 / invoice 10000

WEIGHT: 12.50
SUBJECTIVE: Subjective:
- Skin lesion noted on ventral abdomen after returning from holiday
- Was staying with in-laws who have dogs; one Jack Russell always bothering him
- Owner's wife noticed lesion when picking him up
- Lemmy looking at the area frequently
- Bald spot on lateral aspect from licking/biting
- Licking at the area; was relentless last night but less today as tired from stay
- Otherwise well
Past Medical History:
- Flea/tick/worming up to date
- Yearly check up and vaccination approximately one month ago
OBJECTIVE: Objective:
- Weight: 12.5 kg (consistent with February last year)
- Skin lesion on ventral abdomen; three small bumps noted
- Secondary dermatitis from self-trauma
- Possible insect bites or minor trauma from other dog
PLAN: Assessment & Plan:
1. Hot spot with secondary skin infection
- Diagnosis: Hot spot secondary to possible insect bites or minor trauma from Jack Russell, with secondary dermatitis from self-trauma
- Treatment: Clip and clean of affected area performed; topical cream applied post-cleaning; antibiotics one tablet twice daily for 7 days (with or without food); short course of steroids - 3 days twice daily, then once daily for 3 days, then every second day until finished (weaning dose)
- Cone available if needed; owner to monitor over next few days

HISTORY: History: 
Diet: kibbles 
Urination normal 
Defication normal 
Vomiting N

Worming UTD: Y
Flea and tick UTD: Y
Current medication N

Examination: 
Demeanour- BAR
BCS (1-9) -   7/9               
Eyes- no abnormality detected (NAD)
Ears-  NAD
Teeth/mouth-       Teeth Grade (1-4)       Dental Required N        normal      MM: pink        CRT: <2seconds
Chest    Lungs-      bpm NAD         Heart rate-  130   bpm                   Heart murmur- N
Abdomen- NAD
Hernia          N
Peripheral Lymph Nodes: NAD
Skin- NAD                    
Neurological - WNL
Rectal Exam - Not performed      

Temperature:  Not taken

Desexed Y              

Assessment: Suitable for Vaccination

Vaccination given Nobivac DHP SC , Nobivac KC
Proheart SR 12 0.83 ml SC
Next Vaccination due: 1 year from now KC / proheart SR 12 (DHP Next Due 2028)

Have all reminders been updated for this patient? Y
WEIGHT: 12.50

HISTORY: History: 
Diet:
Urination normal 
Defication normal 
Vomiting N

Worming UTD: Y all wormer
Flea and tick UTD: Y bravecto
Current medication Y/N

Examination: 
Demeanour- BAR 
BCS (1-9) -         7               Ideal Weight - aim 11kg
Eyes- no abnormality detected (NAD)
Ears-  NAD
Teeth/mouth-       Teeth Grade (1-4)   1    Dental Required Y est 570 ikley s&p but discuss extractions from 1250 then 200/teeth         MM: pink        CRT: <2seconds
Chest    Lungs-      NAD         Heart rate-      bpm                   Heart murmur- N
Abdomen- NAD
Hernia          N
Peripheral Lymph Nodes: NAD
Skin- NAD                    
Neurological - WNL
Rectal Exam - Not performed      

Musculoskeletal -   NAD         

Temperature: Not taken

Desexed Y

Assessment: Suitable for Vaccination

Vaccination given Nobivac DHP SC , Nobivac KC
Proheart SR 12 0.83 ml SC
Next Vaccination                  due: 1 year from now          KC /  proheart SR 12  (DHP Next Due 2028)

Have all reminders been updated for this patient? Y
WEIGHT: 12.50