C10002715 / invoice 10000

Reason: Laceration On FootAppointment Notes: 10mins late 3.3.26 SMFRecord Entered by: Vet student ---- Letty Li (DVM4 student) Record Checked by: BIOSECURITY STATUS: white PRESENTING COMPLAINT: Sriracha is a 3yro FS cattle dog presented to UVTHS PC today for a laceration wound on the paw. HISTORY:Last weekend pt's been on a walk and got a cut on the LH limb foot pad. No medication nor treatment was applied around that time. Pt walks with a skipping gait pesistently since the accident. On the walk yesterday the wound seems to have been torn open after intense exercise, as blood patches were seen on the floor. Ox popped on an absorable bandage yesterday after sighting the blood and also due to pt excessive licking of the affected area. SPECIFIC HISTORY:- Urinary incontinence, likely due to USMI given age & desexing status, previous urinary work up unremarkable. Symptoms also responded very well to Stilboestrol, so less likely to be ectopic ureter/conformation problem etc (would need imagining to definitively rule out). No evidence of straining, urine discolouration or discomfort and with chronic symptoms UTI is also unlikely.  NON-SPECIFIC HISTORY:LIFESTYLE: Indoor & Outdoor BEHAVIOUR ISSUES: previous anxiety issue seems to be under control OTHER PETS: noneDIET: Lyka CURRENT OR RECENT MEDICATIONS: on Stilboestrol for urinary incontinence, dispensed Nov last year. 1mg tablets once every week. Needs a refill of Stilboestrol prescriptionAPPETITE,THIRST,COUGHING ETC: Pt usually not a big drinker. No coughing or sneezing, vomiting or diarrhoea. Urinary incontinence happens especially after intense exercise and increased frequency and less intensity noted since pt's been on Stilboestrol. No straining, discoluration or discomfort with urinations seen. VACCINATION: UTD PARASITE PREVENTION (incl. Compliance): Nexgard Monthly, not on tapeworm preventatives PHYSICAL EXAMINATION:WEIGHT:14.3kg FAS SCORE  3/5MENTATION: BAR with good mentationINTEGUMENT:                              	No parasites. Healthy coat and skin. LH limb interdigital space appears erythematous with a healing lesion present, copious saliva stain is present on the dorsal aspect of the paw.MUSCULOSKELETAL:                  	No lameness or ataxia appreciated. Full MSK exam not performed. NEURAL:                                          	Normal, appropriate mentation, full neuro exam not performed. EYES:                                                 	Both visual, corneas transparent, no blepharospasm or epiphora EARS:                                                	Responds to auditory stimulus, ears free of discharge or odour. BODY CONDITION SCORE:        	5/9Other body systems not assessed due to time limitation, pt temperament and localised clinical concerns.  ASSESSMENT:Problem list:1. Healing wound on LH limb interdigital space 2. Occasional urinary incontinence episode notedPatient presented bright, alert and responsive. Due to the patient temperament and time limitation, we cannot perform full physical exam, the LH limb interdigital lesion presented erythematous (ddx: trauma, foreign body embedment, contact dermatitis or atopic dermatitis less likely due to no other body part affected). Suspect the constant licking may have prevented the lesion from healing properly. No detailed examination of the lesion was achieved due to pt temperament and we cannot rule out FB present causing tissue reactions. Thus to control the secondary infection and provide pain relief and if no improvement in 7-14 days, consider sedation and proper examination of the paw +/- x ray to identify any bone fractures. Pt's urinary incontinence seems to be under control appart from the occasional episode after triggers like intense exercise. To continue monitoring and Stilboestrol 1mg once weekly, script dispensed. TREATMENT:- meloxicam oral susp (10ml) 1ml SID with food for 3-5 days, can be extended to 7 days if needed. - cephalexin 300mg 1 tabs BID for 14 days. - soft cone to be kept on for until the recheck - rest for at least 3 days, avoid getting out during wet weather and intense exercise, on leash walk. PLAN (incl. alternative options):1. Recheck in a 1-2 weeks.    Vital Signs