C10022335 / invoice 10000

Reason: Recheck - Yes HeidiAppointment Notes: Overdue remindersHISTORY:  Lexi presented for re-examination of a suspected right anal gland abscess. The owner reports an ongoing issue despite a partial course of antibiotics. The area appears painful and the owner has noticed her licking the perianal area, causing damp fur. There is also a resolving infection between the toes. An associated fishy smell has recurred after initially improving with antibiotics. A previous sedation was required to examine and sample a lump, which was confirmed to be fat.Previous pre-visit sedation with gabapentin (1200mg) and acepromazine (ACP) was administered last night but was not effective in calming Lexi for examination today. The exact dose of ACP administered is unclear. Current meds: Owner has a partial course of antibiotics from the previous visit. Was giving oen tablet twice daily instead of two. EXAMINATION:Examination was performed under sedation due to patient temperament.Body Condition Score: 6/9Pain 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): 1- Abdominal: no detectable pain on abdominal palpation- Rectal: The right anal gland feels normal with no evidence of thickening. The left anal gland was full and expressed.Urinary: NSFReproductive: NSFIntegument/Ears: Resolving interdigital infection.Lymph Nodes: NSFEyes: NSFDemeanour/Behaviour: Anxious and difficult to handle without sedation. PROBLEM LIST:- Suspected right anal gland abscess - resolved.- Full left anal gland.- Perianal pruritus.- Anxious temperament requiring sedation for examination. DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Anal gland impaction/sacculitis.Allergic pruritus. DIAGNOSTICS:Bloods were taken for external laboratory testing.  ASSESSMENT: Lexi presented for follow-up of a right anal gland abscess. Examination under sedation revealed the thickening of the right anal gland has resolved, suggesting the previous abscess responded to antibiotics. The left anal gland was full and was manually expressed. The persistent irritation is likely due to pruritus from underlying allergies now that the anal glands are empty. Bloods were collected for a wellness screen. TREATMENT:  - Sedation was administered for examination.Dexmedetomidine 1.6 ml + ACP 1.3 m PO 3 pmAdditional 0.46 ml Dexmedetomidine + Butorphanol 1.3 ml IM 3:07 pm- Left anal gland was manually expressed.- Zenrelia prescribed for pruritus.- Pre-visit sedation medications (Gabapentin and ACP) were dispensed for future visits. PLAN:- Owner to continue the course of antibiotics at the correct dose until finished.- Administer Zenrelia 1.5 tablets once daily for pruritus.- Monitor for resolution of clinical signs.- Blood test results will be communicated when available in the next few days.- For future visits requiring sedation, the owner was instructed on the correct dosage and timing of pre-visit medications.- Home into owner's care. CLIENT COMMUNICATION:Discussed examination findings, confirming resolution of the suspected abscess. Explained the left anal gland was full and has been emptied, and the ongoing irritation is likely due to allergies. The plan to start Zenrelia for itchiness was discussed, along with the importance of completing the antibiotic course for the paws.The owner consented to a wellness blood test ($230). The importance of correct pre-visit sedative administration for future appointments was emphasised. The owner provided consent for sedation and treatment.    Vital Signs    Weight: 33.2;