C10020841 / invoice 10000

Reason: VaccinationAppointment Notes: Overdue remindersHISTORY:  Presented for vaccination, due to go into a kennel in six weeks. Last vaccination was three years ago (2023). The owner also reported a rash on the abdomen which the patient licks frequently.General health including appetite, thirst, and urination/defecation are normal.Current meds: Infrequent use of a supermarket-brand topical parasite prevention product, brand unknown.Vaccination: Last vaccinated in 2023.Parasite Prevention: Irregularly uses a supermarket brand topical product.Pre-existing conditions: noneAccess to toxins eg. Rodenticide: none EXAMINATION:Body Condition Score: 7/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronous. HR 130bpmRespiratory:thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological:neurologically no significant findingsMusculoskeletal: ambulating normallyGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4):grade 1- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: Erythema on the abdominal and inguinal skin.Lymph Nodes: NSFEyes: NSFDemeanour/Behaviour: Nervous, panting, not receptive to extensive physical examination. History of fear aggression, so examination was limited to avoid stress. PROBLEM LIST:1. Overdue for vaccination2. Overweight (BCS 7/9)3. Erythematous rash on abdomen/inguinal region4. Inadequate parasite prevention5. Grade 1 dental disease6. Anxious behaviour DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Superficial dermatitis (rule out parasitic, allergic, or infectious causes). DIAGNOSTICS:A sticky tape impression of the abdominal skin was performed. Microscopy revealed no significant overgrowth of bacteria. ASSESSMENT:  Louie presented for vaccination catch-up prior to kennelling. He is significantly overweight (9.8kg, BCS 7/9) which is a concern for joint health. Examination revealed an erythematous rash on his abdomen and inguinal area. A skin cytology showed no evidence of bacterial overgrowth, suggesting a non-bacterial dermatitis. Dental disease is mild (grade 1). He is anxious in the clinic. Inadequate parasite control was identified. TREATMENT:  - Vaccinated with C4 and Vanguard B Oral.- Malaseb shampoo prescribed for topical treatment of dermatitis. PLAN:- Owner to commence broad-spectrum parasite prevention (NexGard Spectra or Simparica Trio) monthly.- Start weight management program. Advised to reduce treats and increase exercise.- Bathe with Malaseb shampoo twice weekly during flare-ups, or once weekly for maintenance. Ensure 10 minutes of contact time before rinsing.- Continue home care for dental health with dental chews/treats.- Re-evaluation if skin condition does not improve or worsens.- Home into owner's care.--- 12/03/2026 08:55:42 TLE:Female owner called. She wanted to know why Louie's vaccination was so expensive today. I explained that it was due to a skin cytology performed on Louie's abdomen/ groin area and then the cost of the Malaseb shampoo to treat the skin condition. O kept asking if this is going to be covered by her insurance, to which I explained that I can certainly lodge her insurance for her, however, we don't know what insurances will or wont cover, as this is more a direct question for them based on the policy.    Vital Signs    Weight: 9.8;