C10000335 / invoice 10000

Appointment Notes: Overdue remindersHistory-Update:Consent has been given by the client to proceed with this treatment  -  YesHISTORY:Presented for recheck following a visit to an emergency centre the previous night. The owner reported Jemma Mae had been panting for approximately six hours. At the emergency centre, she received an injection for pain relief, Trazodone, and a topical spray (Savlon) was applied to the perianal area which reportedly caused further irritation. She was initially unsettled but calmed enough to be discharged home.The owner reports Jemma Mae has passed a stool today which was softer than normal, and she urinated last night. A cough is still present, for which she is on antibiotics, though coughing was minimal during the panting episode. The owner checked her gums at home and noted they were pink. There is ongoing skin irritation in the folds under the tail. She is reluctant to lift her tail, although seemed more comfortable during the consultation. The owner is concerned about moisture trapping in the skin folds under her tail.Current meds: Trazodone, AmoxyclavPre-existing conditions: Anxiety, managed with medication. Inter-dog aggression, managed with separation and medication.Access to toxins eg. Rodenticide: noneEXAMINATION:Integument/Ears: Moist dermatitis and erythema noted in the perivulvar and tail folds.LABORATORY:NoneASSESSMENT:Recheck for perivulvar moist dermatitis and anxiety. The panting episode last night was likely secondary to pain/discomfort from the skin and/or anxiety. Examination revealed ongoing inflammation and moisture within the tail and vulvar folds.Problem list:- Moist dermatitis/pyoderma in tail and vulvar folds- Anxiety- Cough (currently on treatment)Differential diagnosis/ Diagnosis:- Moist pyoderma- Behavioural anxietyTREATMENT:NonePLAN:The importance of keeping the area under the tail clean and dry was discussed with the owner. It was advised to clean the area with water and pat it dry thoroughly.Prescribed 10 tablets of Trazodone to be used as needed for anxiety, particularly to facilitate cleaning of the affected area over the weekend. The owner was counselled to wait two hours after administration before attempting to clean the area.Plan to re-evaluate on Monday to assess the skin and determine if a return visit is necessary for cleaning under sedation. The owner will attempt cleaning at home if Jemma Mae is calm enough. The goal is to manage the skin irritation and avoid further stress.Reason: Nurse: -vaccination -heartworm -worming -flea/ticks Exam: Lab: Assessment: Treatment: Plan:--- 28/02/2026 10:16:35 AM VM3:Examinations - Resolved - sent text    Vital Signs    Weight: 22.5;       

Reason: 3 Day POC With VetAppointment Notes: Overdue remindersHistory-Update:Consent has been given by the client to proceed with this treatment  -  YesHISTORY:Jemma Mae presented for assessment of a cough. The owner reports that on Monday, after being fed, Jemma Mae developed a coughing fit between 10:30 and 11:00. She was drinking water and appeared to be overheating. Within two hours, she regurgitated all her food. She was making heavy, phlegmy chest sounds. The cough has been intermittent since then but has been improving. The cough is described as sounding very "chesty". There is concern for aspiration pneumonia.Jemma Mae has also developed an abrasion on her perineum from scratching. This occurred on the drive home on Monday. She is resistant to having the area touched. She has been observed scooting, which may be related to the perineal abrasion or her pre-existing vulvar condition. The owner also noted that Jemma Mae had urinated on herself in the car on the way home.A partial culture and sensitivity report has been received for a skin sample, showing moderate growth of Streptococcus canis. The organism is susceptible to most antibiotics tested, except for doxycycline. Histopathology results for the skin biopsy are still pending. The anaerobic culture is also pending, with results expected in approximately 5 days. It is unclear from the available history which antibiotic was previously used that worsened the skin condition, but it was not amoxicillin-clavulanate, as she has tolerated that previously.Current meds: nonePre-existing conditions: Perivulvar dermatitis.EXAMINATION:Integument/Ears: An abrasion is present on the perineum. There is a noticeable odour reminiscent of the previous bacterial infection.Moist dermatitis likely due to faecal scalding under tail Moist discharge perivulvar LABORATORY:A culture and sensitivity test on a skin sample revealed a moderate growth of Streptococcus canis, which is susceptible to most tested antibiotics.Histopathology and anaerobic culture results are pending.ASSESSMENT:Jemma Mae presented with a productive cough following an episode of regurgitation, raising suspicion for aspiration pneumonia. Examination revealed increased respiratory sounds. There is also a secondary self-trauma abrasion on her perineum, in addition to her chronic perivulvar dermatitis.Problem list:- Productive cough, post-regurgitation- Suspected aspiration pneumonia- Perineal abrasion (self-trauma)- Chronic perivulvar dermatitis- ScootingDifferential diagnosis/ Diagnosis:- Aspiration pneumoniaTREATMENT:Hair around tail clipped (as tolerated) Cleaned with dilute chlorhexPerivular cleaned with dilute chlorhex PLAN:The possibility of aspiration pneumonia was discussed with the owner. A course of antibiotics is recommended to treat the potential respiratory infection and should also be effective against the Streptococcus canis identified on the skin culture.Jemma Mae will be prescribed amoxicillin-clavulanate for a two-week course to treat the suspected pneumonia. The owner was advised that this antibiotic is broad-spectrum and should also help with the skin infection.A re-check appointment has been scheduled for tomorrow at 2:30 PM to reassess her respiratory status and the perineal abrasion. A further reassessment will occur on Monday.The plan for managing the perivulvar skin condition will be finalised once all diagnostic results, including histopathology and anaerobic culture, are available. The owner was informed that the anaerobic culture results may take up to 5 days.Home into owner's care.--- 27/02/2026 08:26:56 AM TLE:Examinations - Resolved - recall txt msg sent    Vital Signs    Weight: 22.5;