Discharge summary

Summary of Xena's visit on 07/28/2025

Doctor: Jennifer Rubinstein, DVM

Tech: Urgent Care Renton

Client

Dan Wheeler

(206) 387-7127

dan@quizkid.net

Patient

Xena

6 years

Intact female

Discharge notes

Presenting Complaint: Xena, a 6 years Intact Female German Shepherd Dog, presented to BoosterPet Urgent Care on 07/28/2025 for some blood, maybe infection in genital area. Large wart/calouses.

Physical Exam:

General appearance: BAR

EENT: No ocular or nasal discharge

Lymphatic: No peripheral lymphadenopathy

Integumentary: Healthy coat. Flea comb found flea dirt, possibly one live flea. Callouses on both hocks with scabbing. Perineum is inflamed with fecal debris. Hair around vulva is discolored

Cardiovascular: No murmurs/arrhythmias, pulses strong, synchronous, mm pk/moist, CRT< 2 sec

Respiratory: Eupneic; lungs clear

Gastrointestinal: Abdomen soft, non-painful on palpation.

Urogenital: External genitalia within normal limits

Musculoskeletal: BCS 5/9, ambulatory x4 with no obvious lameness or weakness

Neurologic: Mentally appropriate, no obvious neurologic deficits.

Plan - recommended flea/tick/HW preventative, clean rectal and area around vulva. Owner has cone and gabapentin at home.

Diagnostics:

- 4Dx Snap test: Negative

Treatments:

- Cleaned perineum/vulvar area. There was some suspected dried blood below her vulva which is suspected to be due to a heat cycle.

Problem list:

Licking at vulva/perineum: may be due to fleas vs. allergies vs. other

Scabs on hocks: these are callouses due to pressure most likely. The scabbing may be due to where she is laying or she is affected by the fleas and chewing/licking them.

Medications prescribed:

See below

Gabapentin: Give 300-400mg every 8-12 hours by mouth for next 5-7 days or until signs stop. Owner has at home. Analgesic. May cause sedation.

Case summary:

Xena was seen today for excessive licking in her perineal/vulvar region. We did find fleas around her tail base. There was discoloration, inflammation around the areas along with some fecal material around her rectum and underneath her tail. All areas were gently cleaned.

We will treat her for fleas and get the areas cleaned-up. She can start the antibiotic and gabapentin. She will need to wear a cone at all times for at least 7 days.

Home Care:

Please clean all areas where she spends time - including floors, furniture and bedding.

Due to the changes in our region, we do recommend continuing the flea/tick/heartworm preventative year-round. She will need a heartworm test annually.

If she misses more than one dose of her preventative, a repeat test is required.

If her condition recurs or worsens, please have her rechecked.

Due to her anxiety/excitement, you may want to give gabapentin 2 hours prior to her next visit.

Thanks for bringing Xena in today. We hope she feels better soon.

We have treated your pet through our BoosterPet Urgent Care service at this time, but we are not a replacement as your pet's primary care provider. Please plan to return to your primary care veterinarian or establish care with a primary care veterinarian for any further follow-up care, unless otherwise specified (i.e. going to a 24/7 ER hospital due to more critical condition).

Prescribed

Simparica TRIO | 72.0 mg Chew Oral Brown Canine 88.1 - 132.0 lbs

Dispense: 6 Chew(s)

Instructions

Administration notes: Give 1 chewable tablet by mouth every 30 days for flea/tick/heartworm prevention. Give with food.

Cephalexin | 500 mg, Capsule, Oral

Dispense: 28 Capsule(s) | Drug expiration: 07/28/26

Instructions

Administration notes: Give 2 capsules by mouth every 12 hours for 7 days. Give with food. Antibiotic.

MiconaHex+Triz | Wipe Topical

Dispense: 1 Bottle | Drug expiration: 07/28/26

Instructions

Administration notes: Apply to affected skin around rectum and vulva 1-2 times daily. Antifungal, antiseptic medication,

Details from Xena's visit

Plan

Medical notes

Presenting Complaint: Xena, a 6 years old Intact Female German Shepherd Dog, presented to BoosterPet Urgent Care on 07/28/2025 for licking at her inguinal area.

History:

The owner reports that Xena has been licking excessively at her genital area and consequent bleeding. The symptoms were noticed about a week ago. Stressors include her other siblings passing, but no others noted. The owner also has concerns about hyperplasia/callouses in her hind legs, which Xena has been biting at. No known history of allergies. Normal urination and defecation.

C/S/V/D: -/-/-/-

E/D/U/D: +/+/+/+

Previous Medical History: Had similar bacterial infection ~5 years ago

Current Medications/Supplements: None

Diet: Purina One and Blue Mountain

Travel History: None

Vaccine Status: UTD

CPR/DNR: DNR

pDVM: Clover Vet Hospital

Urgent Care Renton/Jennifer Rubinstein, DVM

If your pet had a blood draw today, a small bandage has likely been placed. Please remove this bandage within an hour of your discharge.

The vet drained Xena's anal sacs.

Report Card from Vet