C10027265 / invoice 10000

--- 13/03/2026 13:52:59 CK4:Bloods returned:Stable azotaemiaK 6.2Na:K 23.1Chol 9.2Assessment: bloods similar to last.   Can't rule out addisons with resultsDiscussed with O - OK'd resting cortisol to rule out addisons. Aware may need ACTH if inconclusive    Vital Signs    

Reason: Revisit + Talk About SurgeryAppointment Notes: ------- Sms reply: YHISTORY:Jemma Mae is presented for ongoing management of anxiety and chronic vulvar skin fold infections, and a discussion regarding management of her chronic kidney disease.The owner reports worsening anxiety, particularly related to car travel triggered by the lead being picked up and when they prepare to leave the house. Jemma cowers in the bedroom when the owner prepares to leave. The owner is considering a vulvoplasty for the chronic skin fold infections. The area is currently looking much improved and more comfortable, with less scratching. There is still some bacteria present on testing and irritation. The owner describes Jemma scratching the area by sitting down and using her front leg. She can wake the owner at night scratching.Jemma was diagnosed with stage two chronic kidney disease 18 months ago. The owner questions the need for a repeat ultrasound, which was previously recommended. The last ultrasound was performed when she became aggressive towards the other dog in the house, Ada, to check for progression. The first ultrasound was for diagnosis. The last blood tests were likely done at the time of the second ultrasound.Current meds: Half a tablet of Trazodone (150mg) for anxiety, as required for vet visits.Prophylaxis: UTD.Pre-existing conditions: Stage two chronic kidney disease, anxiety, history of brachycephalic obstructive airway syndrome surgery (nasal surgery), history of tail fold infection, hx of aspiration pneumonia.Access to toxins eg. Rodenticide: noneEXAMINATION:Body Condition Score: 7/9Pain 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, no palpable organomegaly or mass lesions noted- Rectal: Not performed.Urinary: NSFReproductive: Marked vulval hooding and skin folds noted. The area appears comfortable and minimally inflamed currently.Integument/Ears: NSFLymph Nodes: NSFEyes: NSFLABORATORY:Blood collected for TAHPUrine Collected for in clinic UAASSESSMENT:Jemma Mae is a dog with multiple chronic conditions including BOAS, stage two chronic kidney disease, significant anxiety (travel-related and separation distress), and chronic vulval fold dermatitis. The consultation focused on long-term management strategies for these issues.The anxiety is significant and impacting quality of life. Medical management can be adjusted, and behavioural modification (desensitisation) was discussed.The vulval fold dermatitis is currently well-managed but chronic, making vulvoplasty a consideration for a permanent solution.The chronic kidney disease is reportedly stable. It was determined that monitoring via blood and urine tests is more valuable than repeat ultrasound unless clinical changes are noted.Problem list:- Anxiety, particularly car-related and separation distress.- Chronic vulval fold dermatitis secondary to conformational abnormalities.- Stage two chronic kidney disease.TREATMENT:NilPLAN:Discussed management of anxiety. The current Trazodone dose can be increased if needed (up to 150mg). Gabapentin can be added as an adjunct therapy. Os happy with current medication and dose at the moment but will increase if needed.  A step-by-step desensitisation program for car travel was advised, starting with associating the lead with positive reinforcement and gradually progressing to being in the car.Discussed vulvoplasty surgery to resolve the chronic skin fold infections. The procedure involves removing the excess skin folds around the vulva. Recovery is approximately 10-14 days. Post-operative care will involve a fentanyl patch for pain relief, managing irritation during healing, and preventing scratching, potentially with socks or a bandage on the foot. Jemma will need to be kept separate from the other dog, Ava, for approximately two weeks post-surgery.The estimated cost for the surgery is around $2500. A pre-approval will be submitted to the insurance company.Pre-anaesthetic management plan discussed to minimise risk of aspiration, given her history. This will include an anti-reflux medication (acid suppressant) for four days prior, medication to tighten the lower oesophageal sphincter, an anti-emetic, and an adjusted anaesthetic protocol to ensure a smooth, gentle recovery and allow for late extubation.It was advised that monitoring chronic kidney disease with blood and urine tests is the priority over repeat ultrasound at this stage, as the disease is likely at a cellular/glomerular level rather than a larger structural one.The owner will collect a urine sample at home and drop it off tomorrow for analysis.We will wait for blood and urine results before booking the surgery. Fortnightly review cleans of the vulval folds will continue in the interim. A follow-up call will be made tomorrow with the results to discuss the next steps.Owner declined referral to a specialist surgeon, preferring the procedure be performed here due to familiarity with Jemma's complex history.Home into owner's care.--- 13/03/2026 08:07:34 AM TLE:Examinations - Resolved - recall txt msg sent--- 13/03/2026 13:52:59 CK4:Bloods returned:Stable azotaemiaK 6.2Na:K 23.1Chol 9.2Assessment: bloods similar to last.   Can't rule out addisons with resultsDiscussed with O - OK'd resting cortisol to rule out addisons. Aware may need ACTH if inconclusive    Vital Signs    Weight: 20.8;