C10012444 / invoice 10000

Reason: Inflamed BottomAppointment Notes: Overdue remindersHistory:HISTORY:  Presenting for a sore bottom for the last three days. The owner reports the area appears inflamed and the patient is licking it frequently. No prior history of this issue. There is a history of sensitive skin, previously treated with injections, but the skin is currently not itchy.Appetite and water intake are normal. No vomiting or diarrhoea reported. Increased frequency of defecation noted one day (three bowel movements instead of the usual one or two), but stool consistency was normal. Current meds: noneVaccination: Not mentionedParasite Prevention: Overdue for heartworm prevention. Owner unsure of current product usage.Pre-existing conditions: Sensitive skin.Access to toxins eg. Rodenticide: none EXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): grade 2-3 dental disease noted.- Abdominal: no detectable pain on abdominal palpation- Rectal: Ruptured left anal gland abscess with a wound present under the anus; discharge expressed from the skin. Expression was too painful to complete. Right anal gland was empty but the wall felt thickened.Urinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: Anxious but cooperative. PROBLEM LIST:- Sore, inflamed perianal area- Left anal gland abscess, ruptured- Thickened right anal gland wall- Grade 2-3 dental disease- Overdue for heartworm prevention DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Left anal gland abscess.Thickened right anal gland wall (inflammation vs neoplasia). DIAGNOSTICS:None ASSESSMENT:Buddy presented for a sore bottom. Examination revealed a ruptured left anal gland abscess. The right anal gland wall felt thickened, which requires monitoring. There is also moderate dental disease present that requires attention. Heartworm prevention is overdue. The owner declined pre-anaesthetic bloods and a heartworm test at this time. TREATMENT:  Medications prescribed:- Antibiotics: three-quarters of a tablet twice daily for 10 days, with or after food. amoxyclav 20mg/kg- Anti-inflammatory: Metacam once daily, with or after food. 0.1mg/kg PLAN:- Re-evaluation in seven days to check the anal glands. If not improving, further expression, flushing under general anaesthetic, or surgery may be required.- Monitor for any adverse effects from medication.- Discussed the need for a scale and polish under general anaesthetic for dental disease.- Advised owner to confirm heartworm prevention status. If not on prevention, a heartworm test will be required before restarting.- Home into owner's care. CLIENT COMMUNICATION:Discussed the diagnosis of a ruptured anal gland abscess. Explained the treatment plan, including antibiotics and anti-inflammatories. Advised on potential side effects of the anti-inflammatory and the importance of monitoring. Cost of the consultation ($100) and anal gland expression ($50) was discussed. The owner was offered a blood test ($240) and heartworm test ($90) but declined at this time, opting to monitor and return if there are any issues. The long-term management of anal gland issues was discussed, including the potential need for flushing under anaesthesia or surgical removal if the problem recurs. The importance of dental health and heartworm prevention was also explained. A follow-up appointment in one week was scheduled.    Vital Signs    Weight: 9.1;       Temperature: NT;       HeartRate: 140;       RespirationRate: pant;