C10005731 / invoice 10000

SubjectivePresenting Concerns:  Ziggy presented for evaluation of a red, raw lesion on his abdomen near his scrotum, which he has been licking constantly. The owners also report lethargy and that he has been licking and chewing at his paws.    Historical Conditions:-   History of previous eye issues described as "buggy," which resolved with medication that has since been discontinued.-   History of skin reactions and sensitivities.  Drinking/Urination:-   The owner reports that Ziggy seems to be struggling to urinate; he will posture for a long time with nothing coming out. This has raised concerns about a possible urinary tract infection.-   He reportedly holds his urine when it is raining.  Skin & Coat:-   The primary concern is a red, raw, and sore lesion on his abdomen near his testicles. This was first noticed on Saturday after he swam in a dam on Friday night.-   He is licking the area constantly, to the point that it wakes the owners at night.-   He has also been observed licking and chewing at his paws.  Lifestyle Risk Factors:-   Swam in a neighbor's dam recently.-   The client's backyard is currently flooded.  Additional Information:-   The patient has been lethargic and sleeping more than usual since the skin lesion appeared.-   He has been sleeping on his back with his legs extended, which the owner believes is to avoid putting pressure on the sore area.ObjectiveMentation: BAR  Wt: —  BCS: --/9  T: Not taken  P: —  R: —  MM: pink/moist. CRT < 2sec.  Hydration: Normal    Emotional Assessment: The patient appeared to be a social dog and allowed for examination.    Eyes: Clear. No discharge or erythema OU.  Ears: Clean with no discharge or erythema AU.  Nose: Clear, moist without discharge.  Throat: No inducible cough upon tracheal palpation; no palpable masses.  Oral: Calculus and gingivitis absent. No masses or other lesions.  Cardiovascular: No murmurs or arrhythmias, strong synchronous pulses.  Respiratory: Normal bronchovesicular sounds bilaterally.  Abdominal: No organomegaly or mass effects. No pain on palpation.  Lymph Nodes: No peripheral lymphadenopathy.  Integumentary: A focal area of pyotraumatic dermatitis (hot spot) is present on the ventral abdomen in the inguinal region. The lesion is erythematous, moist, and appears superficially infected and painful. The hair in the affected area is sparse. Mild erythema was noted on the paws, consistent with licking.  Neurologic: No ataxia, normal mentation.  Musculoskeletal: Ambulation normal, no lameness observed.  Urogenital: The skin lesion is adjacent to the scrotum. The testicles appear normal.AssessmentPyotraumatic dermatitis (hot spot) – A superficial, moist dermatitis is present on the ventral abdomen. This is likely secondary to an allergic or contact reaction, possibly from swimming in a dam, which has led to self-trauma and a secondary bacterial infection.    Suspected allergic skin disease – The presence of a hot spot, along with paw licking and interdigital erythema, is suggestive of an underlying allergic condition.    Stranguria – DDx: behavioral due to pain from dermatitis, urinary tract infection, urolithiasis. The clinical suspicion is that this is behavioral due to discomfort from the adjacent skin lesion, but an underlying urinary issue cannot be fully ruled out.PlanMedications/Treatments:-   A short-acting corticosteroid injection was administered in the clinic for rapid anti-inflammatory effect.-   Oral antibiotics were prescribed. The owner is to give half a tablet BID for 7 days, starting tonight. This can be given with or without food.-   Oral corticosteroids (prednisolone) were prescribed with a tapering dose schedule, starting tomorrow morning:    -   Give 1 tablet SID for 3 days.    -   Then, give a half tablet SID for 3 days.    -   Then, give a half tablet q second day for 3 doses.  Additional Discussion:-   It was recommended to use an Elizabethan collar (cone) at home to prevent further licking and self-trauma to the area.-   The plan is to hold off on shaving the lesion at this time. While shaving is often indicated for hot spots, it can sometimes cause further irritation in this sensitive area, and the hair is already sparse. If the lesion worsens over the next 1-2 days, the recommendation is to return for sedation and clipping of the area.-   The owner was advised to avoid bathing the patient for now.-   If the patient remains very unsettled and continues to lick excessively despite the medication, the owner should call to discuss potential sedatives.-   The owner was advised to continue monitoring his urination and to report any worsening of the signs.    Vital Signs    Weight: 19;