C10023188 / invoice 10000

Reason: Follow UpAppointment Notes: Paws App Details:Booking Type: ConsultationBooking Vet: - Any -Booking Notes: Follow up from Saturday's visitPet Insurance Provider (if applicable): Bow wowPet Insurance Policy # (if applicable): BW23112826SUBJECTIVE:Presenting Concerns:  Daydream, a 10-month-old female dog, presented for lethargy, head shaking, and worsening swelling and inflammation of the left mammary gland. These signs have progressed despite a recent course of antibiotics and anti-inflammatories. The owner also reports inappetence and apparent discomfort during urination and defecation.    Historical Conditions:-   There is a history of a bone ingestion incident that caused subsequent tenderness.-   Previous cytology performed by another veterinarian on the mammary tissue revealed inflammatory cells, but the findings were inconclusive.  Diet/Appetite:-   The owner reports inappetence for approximately 2 weeks, which began before the onset of her current heat cycle.-   She is currently consuming minimal amounts of dry food and is reportedly a picky eater.-   She seems scared to eat, which the owner believes is due to pain associated with defecation.-   She has been holding her feces, resulting in the passage of very large stools.-   Her weight has been stable at 29-30 kg for the last 4 weeks.  Drinking/Urination:-   Drinking has been observed, but the owner's partner noted she may be drinking less than usual.-   The owner reports that Daydream appears to be in pain or scared when she urinates.  Skin & Coat:-   There is a history of pruritus (itching and biting feet) when she was previously fed boiled chicken.  Current Medications:-   The patient was recently on Moxclav and Metacam.-   Metacam was administered last night.-   The owner withheld the Moxclav dose this morning pending the consultation.  OBJECTIVE:Mentation: Bright, alert, and responsive  BCS: --/9  T: 39 °C  P: 116  R: 24  MM: pink/moist. CRT < 2sec.  Hydration: Normal    Emotional Assessment: The patient is a sweet dog but becomes panicked and is very sensitive, particularly to handling of her caudal region. She vocalized loudly when her vulva was gently touched with a cotton swab.    Eyes: Clear. No discharge or erythema OU.  Ears: The AD is extremely erythematous and appears very painful. A strong odor was noted from the AS. An ear infection is suspected.  Nose: Clear, moist without discharge.  Throat: No inducible cough upon tracheal palpation; no palpable masses.  Oral: Calculus and gingivitis absent. No masses or other lesions.  Cardiovascular: No murmurs or arrhythmias, strong synchronous pulses.  Respiratory: Normal bronchovesicular sounds bilaterally.  Abdominal: Palpation was limited due to patient sensitivity. An ultrasound examination was performed.  Lymph Nodes: The regional lymph node associated with the affected mammary gland is enlarged.  Integumentary: The left mammary gland is severely inflamed, hot to the touch, and exhibits significant serous edema. The swelling has increased in size since Saturday.  Neurologic: No ataxia, normal mentation.  Musculoskeletal: Ambulation normal, no lameness observed.  Urogenital: The vulva is massively swollen, firm, and hard on palpation, which is more severe than typical estrous edema. The patient exhibits extreme pain and sensitivity upon examination of the vulva. A digital vaginal examination was attempted but aborted due to the patient's severe reaction.  Rectal: Not performed.    Point of Care Diagnostics:-   Ear Cytology: A sample was collected from the ear for microscopic examination.-   Abdominal Ultrasound: The urinary bladder was visualized and is small (approximately 4 cm in diameter) and not distended. The uterus is not enlarged or fluid-filled, making pyometra unlikely at this time.  ASSESSMENT:Severe Vulvar and Vaginal Inflammation/Hyperplasia – The patient's primary issue is severe, painful, and firm swelling of the vulva, which is atypical for a normal estrus. This is causing significant discomfort and likely dysuria. Vaginal hyperplasia, a condition seen in some bull breeds during estrus, is a strong consideration and can lead to urinary outflow obstruction.    Mastitis, Left Mammary Gland – The left mammary gland is hot, swollen, and painful, consistent with an infection and/or severe inflammation. The condition has not responded adequately to the initial course of antibiotics and anti-inflammatories.    Otitis Externa – Clinical signs, including erythema, pain, and odor, are consistent with an ear infection, primarily affecting the AD. This is a significant contributor to her overall malaise.    Inappetence and Dyschezia – The patient's poor appetite and painful defecation are likely secondary to the significant pain and discomfort from her urogenital and mammary conditions, as well as systemic illness from the ear infection and hormonal fluctuations of estrus.  PLAN:Pending Diagnostics:-   A consultation with a reproduction specialist, Dr. Xavier, will be sought for further advice on managing her condition.-   The ear cytology sample will be examined.  Medications/Treatments:-   Continue Moxclav (three-quarters of a tablet) as directed.-   Continue Metacam as directed for anti-inflammatory effects.-   Add Gabapentin for multimodal pain relief and to promote relaxation, which may help with urination.-   Add Paracetamol at a dose of 1 tablet BID for additional pain management.-   Apply cool packs to the inflamed mammary gland to help reduce swelling and discomfort.-   An ear medication will be dispensed and applied in-clinic today.  Diet & Feeding Recommendations:-   The owner was advised to prioritize caloric intake to support the patient through this illness.-   It was recommended to offer whatever palatable food she will eat, even if it has previously caused mild skin flare-ups.-   A suggestion was made to boil a whole chicken (skin removed), offer the meat, and use the carcass to make a nutrient-rich broth. Rice and vegetables can be added to the broth to encourage intake.  Additional Discussion:-   Close monitoring is essential. A follow-up call is scheduled for this afternoon and tomorrow morning to assess her progress.-   The possibility of an emergency ovariohysterectomy (desexing) was discussed at length. This may become necessary if her condition deteriorates, particularly if she develops a urinary obstruction. The owner was informed that this is a higher-risk and more expensive procedure when performed during estrus due to increased blood supply to the reproductive organs.-   The owner's desire to breed Daydream in the future was acknowledged. The current plan is aimed at managing her medically through this estrous cycle to preserve her fertility, but it was made clear that her health is the priority and desexing may be unavoidable.-   The potential for making an insurance claim for an emergency desexing was discussed, as it would be considered a medically necessary procedure. The Animal Welfare League was also mentioned as a potential lower-cost option if surgery becomes necessary.-   Photos of the vulva will be taken for documentation.--- 12/03/2026 08:57:04 AM HL:Hospital - Resolved - SMS Sent - SC--- 12/03/2026 08:57:06 AM HL:Examinations - Resolved -    Vital Signs    Weight: 30.9;       

Appointment Notes: Overdue remindersSUBJECTIVE:Presenting Concerns:  Daydream, a 9-month-old female entire American Bully, presented for not being herself, showing reluctance to defecate, and for lumps noted by the owner in the caudal abdominal/inguinal area.    Historical Conditions:-   Seen within the last month for a piece of bone that was manually removed from her rectum under sedation.  Diet/Appetite:-   The owner reports inappetence for the last 1.5 weeks, with the patient eating only a mouthful or two at a time.-   She has been tried on softened kibble, boiled chicken (which was discontinued due to paw scratching and licking), dry kibble, and wet food with poor interest.-   She ate a few mouthfuls of a raw diet last night and this morning with encouragement.  V/D/C/S:-   The owner has observed her running with her tail between her legs as if scared to defecate 3-4 times over the last 4 weeks.-   Stools are described as large, and hard but soft.  Skin & Coat:-   The owner reports that Daydream was scratching and eating her paws when she was being fed boiled chicken.OBJECTIVE:Mentation: Bright, alert, and responsive  BCS: --/9  Weight: 30 kg  T: 38.7 °C  P: 116  R: 24  MM: pink/moist. CRT < 2sec.  Hydration: Normal    Emotional Assessment: Friendly, approachable, and affectionate during the examination.    Eyes: Clear. No discharge or erythema OU.  Ears: Clean with no discharge or erythema AU.  Nose: Clear, moist without discharge.  Throat: No inducible cough upon tracheal palpation; no palpable masses.  Oral: Calculus and gingivitis absent. No masses or other lesions.  Cardiovascular: No murmurs or arrhythmias, strong synchronous pulses.  Respiratory: Normal bronchovesicular sounds bilaterally.  Abdominal: No organomegaly or mass effects. No pain on palpation.  Lymph Nodes: No peripheral lymphadenopathy. Inguinal and popliteal lymph nodes were non-palpable.  Integumentary: The caudal mammary chains are affected bilaterally, with the left side being larger than the right. Mild skin irritation was noted in this region.  Neurologic: No ataxia, normal mentation.  Musculoskeletal: Ambulation normal, no lameness observed.  Urogenital: The vulva is markedly swollen, red, and inflamed.  Rectal: Not performed.    Point of Care Diagnostics:-   Vaginal Cytology: Revealed a high number of degenerative neutrophils and parabasal cells with nuclei present. Two cocci were seen intracellularly within a neutrophil. Scant bacteria were present overall. Findings are consistent with proestrus.-   Mammary Fine Needle Aspirate (Left Caudal Gland): Sample collected. Cytology was reviewed in-house and considered equivocal.ASSESSMENT:Bilateral Caudal Mammary Gland Swelling and Vaginitis – DDx: Mastitis, mammary hyperplasia secondary to impending estrus. The patient is a 9-month-old entire female presenting with signs consistent with her first heat cycle (proestrus), including significant vulvar swelling and behavioral changes. Cytology of the vagina shows inflammation and changes consistent with proestrus. The mammary swelling is suspected to be either inflammatory (mastitis) or hyperplastic in response to hormonal changes. Neoplasia is considered highly unlikely given her age.    Hyporexia and Dyschezia – Likely secondary to systemic effects and discomfort associated with the impending estrus cycle and associated mammary and vulvar inflammation.PLAN:Pending Diagnostics:-   The mammary aspirate cytology slides have been retained. If there is no improvement with initial treatment, the slides will be submitted for formal pathologist review.  Medications/Treatments:-   A course of oral Metacam was dispensed to be given SID to manage inflammation and discomfort.-   A 6-day course of oral amoxicillin-clavulanate was dispensed as a proactive measure for suspected mastitis.-   The owner was advised to stop the Metacam if any vomiting or diarrhea occurs as it can cause gastrointestinal upset.  Diet & Feeding Recommendations:-   It was recommended to start probiotics to support gastrointestinal health, especially while on medication.-   To improve appetite, it was suggested to try adding cooked kangaroo mince or a Prime 100 casserole as a food topper. Serving the food warm may also help entice her to eat.  Additional Discussion:-   A recheck examination is recommended if she becomes lethargic, if her appetite does not improve, or if the mammary glands increase in size.-   The owner was advised to monitor for the onset of a true heat cycle (bleeding).-   The total cost for today's consultation, cytology, and medications is approximately $300. The owner paid at the time of service and will be provided with a receipt to submit an insurance claim, as the clinic could not process a direct GAP payment after hours.--- 09/03/2026 12:00:42 PM SKC:Examinations - Resolved - SMS Sent - SC    Vital Signs    Weight: 30.2;