C10010781 / invoice 10000

History:  Presenting for assessment of perineal irritation and discomfort. Cookie was at an emergency centre and discharged yesterday morning for assessment of vomiting and diarrhoea. The last episode of diarrhoea was yesterday afternoon. This morning's faeces were paste-like. The owner reports Cookie is licking her perineal area frequently, is restless, and "scooting" on the floor. She is uncomfortable when the owner attempts to clean the area.The last episode of vomiting was last Thursday.Eating small amounts of cooked chicken but refusing rice. Drinking normally.Current meds: Pro-Colon, one dose remaining. Previously on Omeprazole and Ondansetron wafers which have been discontinued.Access to toxins eg. Rodenticide: noneDiet: Cooked chicken.Prophylaxis: UTD.Pre-existing conditions: noneExamination:  Demeanour: BAR HR: WNLRR: WNL Thoracic auscultation: No murmurs or arrhythmias auscultated, normal BVS on all lung fields Temperature: Not taken Body Condition Score: 5/9MM: Pink/moist CRT: <2 seconds Ears: Clean bilaterally, no masses, swelling or evidence of ectoparasite visualised. Eyes: WNLs bilaterally.Nose: NADOral: Grade 0/4, NADIntegument: Perineal dermatitis noted. Remainder of integument is healthy with a clean coat, no masses or swellings palpated. MSK: No lameness at the walk, full exam not performed. Lymph nodes: Peripheral LNs WNLs.Abdominal palpation: Soft, comfortable, no masses palpated, no pain elicited. Increased borborygmi noted.Urogenital: Not examined Neurological: Normal mentation  normal gait, no obvious CN deficits, full exam not performed Rectal: Not performed due to patient discomfort.Pain Scale (0-4): 0/4Assessment:  - Gastroenteritis - resolving.- Perineal dermatitis secondary to diarrhoea.Treatment:  - Continued Pro-Colon 6ml daily for 5 days.- Owner has Neocort ointment at home to apply to the affected skin twice daily.- Faecal sample jar provided for testing if desired by owner.Consent has been given by the client to proceed with this treatment  -  Yes   Plan:- Continue bland diet (cooked chicken).- Apply ointment to perineal region twice daily.- Use an Elizabethan collar to prevent licking, especially when unsupervised or overnight.- Owner to collect a faecal sample for analysis.- Re-present if there is any recurrence of vomiting, lethargy, inappetence, or worsening of diarrhoea.- Home into owner's care. CLIENT COMMUNICATION:Discussed that the clinical signs are consistent with resolving gastroenteritis and secondary skin irritation. Emphasised the importance of preventing licking of the perineal area by using an Elizabethan collar. Advised to continue the bland diet and probiotics. --- 10/03/2026 09:16:13 AM HEK:Examinations - Resolved -    Vital Signs    Weight: 6.8;