C09988697 / invoice 10000

Presenting Complaint:
Skin check.
Gnawing at base of tail.
Panting and seems uncomfortable since yesterday.

Hx:
Yesterday was very off-colour and panting.
Gnawing at his tail/bottom area.
Owner notes redness on the right side of his body.
History of a similar issue a couple of years ago.
Yesterday was scooting his bottom on the ground, which is unusual.

PEx:
Temperament: Anxious and sore.
BCS:
MM: pink and moist, CRT: 1-2 sec
Mouth: NAD
eyes: NAD
ears: NAD
nose: NAD
Cardiovascular: HR: Murmur: No
Respiratory: lung sounds are normal
Lymph nodes: NAD
Abdominal Palpation: NAD
Skin/Coat: Focal barbered fur around backside. Redness noted by owner.
Musculoskeletal: NAD
Genitalia: NAD
Rectal temperature: 39.4
Other Issues: Swelling and tenderness noted on the right side over the anal gland area.

Laboratory results:

Assessment:
Mild pyrexia.
Bilateral impacted anal glands, worse on the right side.
Perianal skin irritation secondary to self-trauma.
Expressed both anal glands, contents were thick but not purulent.

Plan:
Apply bacticorten cream to the affected skin twice a day for 5 days. Do not insert the cream.
Advised owner to monitor for licking/chewing and prevent if possible.
Recheck anal glands in 6 weeks to monitor for recurrence.
Advised owner to book for intermittent anal gland expression if they become full again to prevent pain and potential rupture.
Monitor for signs of discomfort such as scooting, wiring at the bottom, or looking around at his tail.

Consult Summary:
Presented for gnawing at tail base and discomfort.
Diagnosed with impacted anal glands.
Anal glands expressed during consult.
Dispensed cream for skin irritation.
Recommended recheck in 6 weeks.

Simba presented for Lepto 2 booster 

O says Simba has been well at home
EDDU all normal, no v+ or d+
O says Simba is a very anxious dog, even at home, doesn't like the car, the vets
Panting and evasive in consult, minimal exam due to behaviour
No reaction to last vaccine
Tried to place muzzle but Simba does not tolerate it well, ME held instead and O's gave lots of head pats
Simba good for this, Lepto booster given subcut with no issues
Batch # A003A01, Exp: 10/26

RP

Presenting Complaint: Vaccination.

Hx: In good health according to owner, no current concerns, eating, drinking, urinating and defecating normally. 
Diet: Kibble with cooked chicken or mince on top. 
Parasite Preventive: Spot-on due in February.

PEx: 
Temperament: Anxious.
BCS 6/9
MM pink. 
Cardiovascular: HR: 132 = PR. Murmur: No
Respiratory: RR = 36, lung sounds are normal
Abdominal Palpation: NAD
Skin/Coat: NAD
Musculoskeletal: NAD

Assessment: 
Healthy dog presented for vaccination.

Plan: 
Administered Nobivac Lepto 2 SC. 
Advised owner that a booster for the Leptospirosis vaccine is required in 2-6 weeks.
Advised that lethargy for a few hours post-vaccination is possible.
Advised to contact the clinic if any concerns arise.
Annual vaccines are due in May.