C09994358 / invoice 10000

Dipstick:LEU - 1+NiT - negpH - 7PRO - 1+Glu - normKet - negUBG - normBIL - negERY - 1+USG - 1.036

HISTORY/REASON FOR VISIT- Lola has been licking excessively at her vulval area over the last week, O initially thought it might be a grass seed- Has had an Elizabethan collar on her to stop her licking over the last few days.- Owner unsure if she has had some urine incontinence or if wetness is from excessive licking- Due for vaccination next week- Patient is 12.4kg, has gained over 1kg in the last year- Owner has reduced her diet by 1/4 over the last fortnightPHYSICAL EXAM:Demeanour - BARBCS - WNLCardiovascular - HR WNL, No murmurs or arrhythmias auscultated.Respiratory - RR WNL. Normal respiratory effort, auscultation WNLMM colour/CRT - Eyes - NSFEars - NSFNose and Throat - NSFOral Assessment - NSFUrogenital - Perivulval skin irritation and inflammation noted, some self trauma from licking, recessed vulva noted due to body conditionMusculoskeletal - NSFNeurological - basic neuro exam WNLIntegument - Perivulval and ventral caudal abdomen papulesPalpate Peripheral LN's - NSFAbdominal palpation - bladder small and non painfulRectal - Little bit of discharge from anal glands but not blockedTemperature - 39PROBLEM LIST:Perivulval irritation and excessive licking - cystitis, urinary tract infection, skin fold dermatitis secondary to recessed vulva, allergic dermatitisWeight gain - overfeeding, lack of exercise, metabolic diseaseTREATMENT:Neocort cream topically BID for 5-7 daysShort course neocorthead collar at all timesPLAN / DISCUSSION WITH OWNER:- Clipped hair around affected area for better visualization and airflow- Dispensed tablets to give once daily- Advised diet reduction and discussed possibility of switching to sensitive skin and satiety diet- Provided urine collection jar for first morning catch sample- Advised to bring urine sample at vaccination appointment next Friday- If symptoms persist, urinalysis will be performed to check for urinary tract infection- Vaccination can still proceed on Friday if patient is well

Eyes back to normalPlan:Pred once daily for a further 2 weeksHyloforte once daily for a further 2 weeksRecheck if recuring