C09986647 / invoice 10000

Primary Presenting Complaint:
Swelling around vulvar area

Other Complaint:
History of allergies

History:
Recent dental scaling procedure performed. Owner has been dealing with personal health issues which may have delayed recognition of current problem.

    - Last Normal - Approximately one week ago when swelling first noticed
    - Frequency - 
    - Last Ate - 
    - Vomiting - 
    - Stool - 
    - Urination - 
    - Drinking - 
    - Medicine Hx - Currently on medication following dental procedure
    - Diet - 
    - Vacc Current - 
    - Worming Hx - 
    - Heartworm - 
    - Microchip - Y/N - scanned - ok?

Examination:
Perivulvar dermatitis with secondary infection requiring topical and systemic treatment

    - Attitude - BAR
    - Body Score - 6/10
    - Hydration status - wnl 
    - Temperature - 39
    - Heart - ~100 HR. Murmur - nil
    - RR - wnl
    - Dental - Score(0-4)= G0
    - CRT - immediate
    - Eyes - NVL
    - Ears - clean and discharge free
    - Abd Palpation - Unremarkable
    - Gastrointestinal - No Sig Findings
    - Urogenital - Vulvar area markedly inflamed and swollen. Pink discoloration of ventral abdomen noted.
    - Skin - Significant perivulvar dermatitis with possible pyoderma. Erythematous, inflamed skin around vulvar region. Evidence of self-trauma from excessive licking.
    - Musculoskeletal - No Sig Findings
    - Neurological - No Sig Findings
    - Lymphatic - No Sig Findings
    - Other Key Findings - 

Assessment:
Perivulvar dermatitis with secondary bacterial infection (pyoderma). Self-traumatizing behavior exacerbating condition by introducing oral bacteria into compromised skin barrier.

Problem List:
1. Perivulvar dermatitis
2. Secondary pyoderma
3. Self-trauma from licking behavior
4. History of allergies
5. Recent dental scaling

DDx:
Primary diagnosis: Perivulvar dermatitis with secondary bacterial pyoderma
DDx for vulvar inflammation: Ovarian remnant syndrome (given anatomical location and potential for systemic complications)

Discussed:
Owner consented to treatment plan including medications and E-collar use. Discussed that dog's licking behavior is introducing oral bacteria (especially significant given recent dental disease) into already compromised skin barrier, worsening infection. Counseled about potential for ovarian remnant syndrome complications given anatomical location of inflammation - instructed to monitor for lethargy, vomiting, or inappetence and return immediately if these signs develop. Owner understands need for E-collar compliance for minimum one week to allow healing. If condition does not improve or worsens, may require further investigation for underlying causes including potential ovarian remnant tissue.

Treatment Plan:
1. Apoquel tablets BID until course completed for anti-inflammatory effect
2. Antibiotics dispensed (course to be completed) - cephalexin 
3. Topical cream to be applied as thin layer to affected perivulvar and ventral abdominal areas, rubbed in well - sudocream 
4. E-collar to be worn for minimum 1 week to prevent self-trauma
5. Area was cleaned during consultation

Next Visit:
Return immediately if develops lethargy, vomiting, or inappetence. Otherwise recheck as needed if condition does not improve with current treatment protocol.

The above clinical notes were created with the assistance of Astro Scribe under the supervision of the consulting Vet.

GR: #5 a/o incl skirt and chest. Trim head and tail. Tidy ears. TLC - warts on neck and under front paw TP $90
Vet to do AGs

Primary Presenting Complaint - 
Other Complaint - 
         Loyalty Reward Program - Y/N
History - Attacked by a willy wag tail 
         Last Normal -
         Frequency   -
         Last Ate       -
         Medicine Hx  -
         Diet              -
         Vacc Current -
         Worming Hx  -
         Heartworm    -
         Microchip       -  Y / N    -  scanned - ok?

Examination -
         Attitude -
         Body Score -    /10
         Temperature - 
         Heart -   HR. Murmur - 
         RR -
         Dental - Score(0-4)=    .Comment
         CRT - immediate
         Eyes - NVL
         Ears - clean and discharge free
         Abd Palpation - Unremarkable
         Gastrointestinal -  No Sig Findings
         Urogenital -  No Sig Findings
         Skin - Small infected graze on L lower lip 
         Musculoskeletal -  No Sig Findings
         Neurological -  No Sig Findings
         Lymphatic - No Sig Findings
         Other key findings = 

Assessment - 
Problem List - 
DDx                 - 
Discussed      - 
Treatment - Cephalexin, meloxicam
Plan - 
Prescriptions(on-going) -
Next Visit            -