C10007401 / invoice 10000

02/02/2026 Subjective:

- Presenting for: Maggie presenting for recheck of a left anal sac abscess treated with antibiotics started 3 days ago.
- Past History: Seen 3 days ago for an infected left anal sac abscess and started on antibiotics.
- History of Present Illness: Owner reports the swelling has gone down and the area appears much better and closed over, but Maggie still seems uncomfortable and continues to look at the area. She inappetence last night.
- Onset: Anal gland abscess diagnosed 3 days ago; since then swelling has markedly improved but discomfort persists. No feces passed today.
- C/S/V:
  * Not coughing, not sneezing and no vomiting

- E/D/U/D:
  * Decreased appetite (inappetence last night)
  * Defecation: no feces passed today, no observed tenesmus
  * Eating not normal, drinking status not reported, urinating status not reported, defecating not normal

- Current Medications:
  * Antibiotics for infected anal sac abscess (started 3 days ago) - continue (specific drug, dose, route, and frequency not stated)


Vitals:

- Temperature: 38.5 °C, method not stated, 5:27 PM

Physical Exam:

- General Appearance & Behavior: BAR, friendly
- Hydration Status: Euhydrated, normal skin tent, MM pink and moist, CRT <2 sec
- BCS /9: /9
- Nasal Cavity: NSF, no nasal discharge noted
- Oral Cavity: NSF, no significant plaque, tartar, gingivitis noted
- Eyes: NSF, clear and free of discharge, pupils normal size, globes symmetrical OU
- Ears: NSF, no discharge observed, no erythema present AU
- Lymph nodes: NSF, no peripheral lymphadenopathy noted
- Integument: Left perianal region: previously swollen area now markedly reduced in size and closed over, consistent with healing.
- Musculoskeletal: NSF, normal ambulation x4, normal muscle mass
- Thyroid: NSF, no enlargement or painful palpation noted
- Cardiovascular: NSF, no murmurs or arrhythmias noted, pulses strong and synchronous
- Respiratory: NSF, eupneic, lungs sounds clear in all 4 quadrants; no cough elicited on tracheal palpation
- Abdomen: NSF, no pain notes in abdominal palpation; no masses or organomegaly noted
- Urogenital: NSF, no discharge noted. No abnormalities notes on bladder or kidney palpation
- Neurologic: NSF, normal mentation, no obvious deficits notes, full neuro exam not performed

Assessments:

- Problem List:
  * Resolving left anal sac abscess - marked reduction in swelling and closure of lesion on recheck after 3 days of antibiotics
  * Hyporexia - owner reports not eating dinner last night, likely associated with recent condition and treatment
  * Decreased fecal output - no feces passed today without tenesmus, likely secondary to decreased intake


Plan:

- Owner Discussion:
  * Discussed that the anal gland abscess appears massively improved with the area closed over and swelling much reduced.
  * Advised to continue the current antibiotic course until completion.
  * Discussed that lack of defecation today is acceptable given decreased food intake and absence of straining.
  * Planned a final recheck in one week to coincide with completion of antibiotics, including a digital rectal examination to ensure resolution.
  * Owner plans to schedule monthly anal sac expressions moving forward.

- Monitoring: Monitor appetite, discomfort at the perianal area, and bowel movements. Return sooner if swelling recurs, lesion reopens, pain worsens, or systemic signs develop.
- Follow Up: Recheck in 1 week for final assessment and rectal exam. | 02/03/2026 Recheck LHS anal sac abscess
Certainly improving
The swelling has gone right down
There is still a small defect in the skin
Rectal exam - right hand side contains a small amount of material

Advise remain on antibiotics and recheck 14 days

Subjective:

- Presenting for:
- Medical History:
    * Owner reported prior perianal issue with concern about anal sacs and licking; owner has been trying to prevent licking.
    * Owner reported no diarrhoea while on antibiotics.
    * Owner requested clarification if anal sacs needed to be expressed.

Assessments:

- Left perianal swelling
- History of recent anal sac issue, improving on antibiotics

Plan:

- Owner Discussion:
    * Discussed that the left side shows mild residual swelling without inflammation and the right anal sac is not markedly distended.
    * Advised continuing antibiotics for an additional 2 weeks to ensure complete resolution and reduce risk of recurrence.
    * Confirmed no GI upset to date on antibiotics.
    * Recommended recheck examination in 2 weeks to reassess and ensure resolution.
    * Owner agreed to continue antibiotics and to return for the recheck.

- Diagnostics:
- In-Hospital Treatments:
- Medications Prescribed:
    * Antibiotics: continue current course for an additional 2 weeks (exact drug, dose, route, and frequency not stated).

- Vaccines:
- Diet:
- Monitoring: Monitor the perianal area for increased swelling, redness, discharge, pain, or recurrence of licking; monitor for antibiotic-associated diarrhoea and discontinue and contact the clinic if adverse effects occur.
- Follow Up: Recheck in 2 weeks.

 | 02/02/2026 Subjective:

- Presenting for: Maggie presenting for recheck of a left anal sac abscess treated with antibiotics started 3 days ago.
- Past History: Seen 3 days ago for an infected left anal sac abscess and started on antibiotics.
- History of Present Illness: Owner reports the swelling has gone down and the area appears much better and closed over, but Maggie still seems uncomfortable and continues to look at the area. She inappetence last night.
- Onset: Anal gland abscess diagnosed 3 days ago; since then swelling has markedly improved but discomfort persists. No feces passed today.
- C/S/V:
  * Not coughing, not sneezing and no vomiting

- E/D/U/D:
  * Decreased appetite (inappetence last night)
  * Defecation: no feces passed today, no observed tenesmus
  * Eating not normal, drinking status not reported, urinating status not reported, defecating not normal

- Current Medications:
  * Antibiotics for infected anal sac abscess (started 3 days ago) - continue (specific drug, dose, route, and frequency not stated)


Vitals:

- Temperature: 38.5 °C, method not stated, 5:27 PM

Physical Exam:

- General Appearance & Behavior: BAR, friendly
- Hydration Status: Euhydrated, normal skin tent, MM pink and moist, CRT <2 sec
- BCS /9: /9
- Nasal Cavity: NSF, no nasal discharge noted
- Oral Cavity: NSF, no significant plaque, tartar, gingivitis noted
- Eyes: NSF, clear and free of discharge, pupils normal size, globes symmetrical OU
- Ears: NSF, no discharge observed, no erythema present AU
- Lymph nodes: NSF, no peripheral lymphadenopathy noted
- Integument: Left perianal region: previously swollen area now markedly reduced in size and closed over, consistent with healing.
- Musculoskeletal: NSF, normal ambulation x4, normal muscle mass
- Thyroid: NSF, no enlargement or painful palpation noted
- Cardiovascular: NSF, no murmurs or arrhythmias noted, pulses strong and synchronous
- Respiratory: NSF, eupneic, lungs sounds clear in all 4 quadrants; no cough elicited on tracheal palpation
- Abdomen: NSF, no pain notes in abdominal palpation; no masses or organomegaly noted
- Urogenital: NSF, no discharge noted. No abnormalities notes on bladder or kidney palpation
- Neurologic: NSF, normal mentation, no obvious deficits notes, full neuro exam not performed

Assessments:

- Problem List:
  * Resolving left anal sac abscess - marked reduction in swelling and closure of lesion on recheck after 3 days of antibiotics
  * Hyporexia - owner reports not eating dinner last night, likely associated with recent condition and treatment
  * Decreased fecal output - no feces passed today without tenesmus, likely secondary to decreased intake


Plan:

- Owner Discussion:
  * Discussed that the anal gland abscess appears massively improved with the area closed over and swelling much reduced.
  * Advised to continue the current antibiotic course until completion.
  * Discussed that lack of defecation today is acceptable given decreased food intake and absence of straining.
  * Planned a final recheck in one week to coincide with completion of antibiotics, including a digital rectal examination to ensure resolution.
  * Owner plans to schedule monthly anal sac expressions moving forward.

- Monitoring: Monitor appetite, discomfort at the perianal area, and bowel movements. Return sooner if swelling recurs, lesion reopens, pain worsens, or systemic signs develop.
- Follow Up: Recheck in 1 week for final assessment and rectal exam.