C09989450 / invoice 10000

Reason: Discharge From PenisAppointment Notes: Special payment terms existPrimary Presenting Complaint:Penile/preputial dischargeOther Complaint:History:2-day history of clear discharge from prepuce. Dog licking area. Other household dog showing interest in the area (suggesting odor present).    - Last Normal - Normal urination pattern, no straining    - Frequency -     - Last Ate -     - Vomiting -     - Stool -     - Urination -     - Drinking -     - Medicine Hx -     - Diet -     - Vacc Current -     - Worming Hx -     - Heartworm -     - Microchip - Not mentioned/not scanned during this visitExamination:Clinically stable patient presenting with mild preputial inflammation    - Attitude - BAR    - Body Score - 7/10    - Hydration status - Normal/adequate    - Temperature -     - Heart - HR 108. Murmur - NIL    - RR - panting normal bv sounds     - Dental - Score(0-4)= Dental disease stage 2/4    - CRT - immediate    - Eyes - NVL    - Ears - clean and discharge free    - Abd Palpation - Abd palp WNL, bladder WNL    - Gastrointestinal - No Sig Findings    - Urogenital - Mild erythema at tip of prepuce. Mild inflammation of preputial tissue. Small volume green to yellow mucoid discharge present. No ulceration or skin breakdown. No pain on palpation. Peripheral inguinal lymph nodes WNL.    - Skin -     - Musculoskeletal - No Sig Findings    - Neurological - No Sig Findings    - Lymphatic - No Sig Findings    - Other Key Findings - Other household dog (4yo) showing behavioral interest in affected areaAssessment:Mild preputial inflammation consistent with possible early balanoposthitis. Differential includes normal physiological discharge vs early bacterial infection secondary to self-trauma from licking.Problem List:1. Mild preputial inflammation with clear discharge2. Dental disease stage 2/43. BCS 7/10DDx:DDx for preputial discharge/inflammation:1. Normal physiological smegma accumulation2. Early balanoposthitis (bacterial)3. Self-trauma from excessive licking leading to secondary inflammation4. Change in local bacterial floraDiscussed:Discussed with owner that mild preputial discharge can be normal, but given the inflammation and behavioral changes (licking, other dog's interest), recommended urine collection to rule out bacterial infection. Owner consented to free-catch urine sample collection at home. Explained that if infection is caught early, it can be managed before progressing to more significant balanoposthitis. Owner comfortable with plan and will monitor for worsening signs including increased discharge, color change, dysuria, or increased licking behavior.Treatment Plan:Collect free-catch urine sample for urinalysis with cytology to rule out bacterial infection. Owner to collect out the front of reception if possible, or at home during walk.Ongoing Prescriptions:Next Visit:Return if signs worsen (increased discharge, color change, dysuria, excessive licking) or for follow-up once urine results availableThe above clinical notes were created with the assistance of Astro Scribe under the supervision of the consulting Vet.    Vital Signs    Weight: 26.6;