C09970700 / invoice 10000

Reason: Rash On BellyAppointment Notes:   26.02.2026  TBRecord Entered by: Vet student ---- Brian TO  Record Checked by: jn BIOSECURITY STATUS: White  PRESENTING COMPLAINT: Rashes on belly HISTORY: SPECIFIC HISTORY:Romeo was presented today for rashes on his belly. The owner noticed that a rash started to develop on the ventral abdomen since 10 days ago. Romeo was licking and scraching his belly all the time even when the owners tried to stop him. Romeo was so itchy that he was not able to sleep at night at well. He is particularly itchy at the belly, the paws and the groin.  Romeo has a few episodes on the belly before, which usually get resolved when the owners use chlorhexidine on the lesion. Howver, the owners do not think that Chlorhexdine is not really helping for this time. Romeo has not received any oral medication or injection for his skin condition before. Romeo has also been diagnosed with stage B2 MMVD earlier this year, which is currently managed with pimobendan. The owners think that the condition has been stable, as they did not observe any increase in respiratory rate and effort at home. NON-SPECIFIC HISTORY: LIFESTYLE: Indoor/Outdoor/Indoor & Outdoor: Indoor and outdoor BEHAVIOUR ISSUES: At Vet/At Home - A bit aggressive when belly or back-end was touched  OTHER PETS: N/A  DIET: Blackhawk Kibble CURRENT OR RECENT MEDICATIONS:   Pimobendan   APPETITE,THIRST,COUGHING ETC: EDDU all normal and consistent. No coughing or sneezing, vomiting or diarrhoea VACCINATION: UTD PARASITE PREVENTION (incl. Compliance): Nexgard Spectra  PHYSICAL EXAMINATION:WEIGHT:                                             9.1 kg FAS SCORE                                        2/5:MENTATION:                                       BAR HR:                                                     108 PULSE QUALITY:                            	strong, synchronousRR:                                                     	40 TEMPERATURE:            	                ---INTEGUMENT:                              	An extensive, coalescing erythematous, moist lesion on the ventral caudal abdomen and the inguinal area. Painful when the lesion was palpated. CIRCULATORY:                     MM = Pink & Moist, CRT<2s. A moderate intesnity heart murmur can be easily auscultated RESPIRATORY:              No wheezing or crackles, normal bronchovesicular sounds bilaterally.DIGESTIVE: No palpable abnormalities on superficial or deep palpation of abdomen. Comfortable on palpation.Oral Cavity:                 	           Moderate amount of calculus accumulation and mild gingivitis GENITOURINARY: No discharges from prepuce/vulva. Desexed animal. Bladder small and comfortable, kidney palpation unremarkable.MUSCULOSKELETAL:      No lameness or ataxia appreciated. Full MSK exam not performed. NEURAL:                         Normal, appropriate mentation, full neuro exam not performed. LYMPH NODES:              Lymph nodes symmetrical and normal size and consistencyEYES:                             Both visual, corneas transparent, no blepharospasm or epiphora EARS:                            Responds to auditory stimulus, ears free of discharge or odour. BODY CONDITION SCORE:        	5/9 IN-HOUSE DIAGNOSTICS:- Sticky tape sample taken from ventral abdomen, interdigital area of front and back paws - Moderate - Marked amount of inflammatory cells and Cocci from the abdomen sample - Mild - moderate amount of cocci from the interdigital sample  ASSESSMENT:Problem list:1. Superficial cocci Pyoderma on ventral caudal abdomen 2. Stage B2 Myxaous Mitra Valve disease Include your clinical impression of the animal: The extensive erythema on the ventral caudal abdominal and inguinal area suggested a major inflammatory response of the area. The presence of cocci and inflammatory cells suggested a secondary bacterial infection (pyoderma). Possible underlying cause of pyoderma include licking of the area atopic dermatitis, food allergy, insect-bite hypersensitivity etc. Therefore, a cytopoint injection is recommended to control the itchiness and inflammation. Since the pyoderma is extension and penetrating to deeper layer, an oral course of Cephalexin is recommended in additional to topical antibiotic. Romeo appeared to be quite painful and irritated when the erythemaous lesion was touched. Therefore, a course of Pregabalin was indicated to manage the chronic and neuropathic pain. A course or Flamazine is also administered as topical antibiotic.  Since the erythematous lesion was quite painful. It is recommended to start the topical Flamazine treatment 24 hours after pain-relief medication started. We avoided Prednisolone topical due to the extensive are and risk of absorotion and cause cardiac complications, and also avoided oral steroids for same reason. TREATMENT:1. Cytopoint injection given - Batch number: 828805- Expiry date: 01/202725 mg/kg cephalexin q 1 2hours 21 days2.7 mg/kg pregabalin q 12 hours 14 days Flamazin TID  (start 24 hours after Ecollar, cephalexin and pregabalin because very painful atm) E collar at all times 0.27 mg/kg Pimobendan chewable 2.5 mg q 1 2hours PLAN (incl. alternative options):1. Give 2 and 1/4  tablets of Cephalexin every 12 hours with food for 21 days 2. Give 1 capsule of Pregablin every 12 hours with / without food for 14 days 3. Apply Flamazine cream on the abdominal lesion 3 times daily for 14 days (start tomorrow afternoon) 4. Apply an ecollar for 14 days 5. Arrange a recheck in 3-4 weeks 6. Advised to use Cardalis apps to monitor Resting Respiratory Rate at home. PHARMACY PRESCRIPTIONDATE:					2026/02/27CLIENT'S NAME:			Mitchell Blundell CLIENT'S ADDRESS:			6/32 Gibbens StreetCamperdownNSW2050PATIENT'S NAME:			RomeoSPECIES:				DogPATIENT’S WEIGHT:			9.1*****************************FOR ANIMAL USE ONLY*****************************MEDICATION:	cephalexin 200 mg scored tablet 			PRESCRIBED DOSE: 	Give 2 and ¼ tablets (225 mg)  every 12 hours with food for 21 days 		QUANTITY PRESCRIBED:	100	AUTHORISED REPEATS: 	0	PRESCRIBING VETERINARIAN: 	Dr Jorid Nordaker V9034QUALIFICATIONS: 	BVSc MTch		VETERINARIAN SIGNATURE:                                                                                        MEDICATION:	Pregabalin 25 mg capsule 			PRESCRIBED DOSE: 	One capsule every 12 hours with or without food for 14 days 		QUANTITY PRESCRIBED:	30	AUTHORISED REPEATS: 	0	PRESCRIBING VETERINARIAN: 	Dr Jorid Nordaker V9034QUALIFICATIONS:  BVSc MTch 			VETERINARIAN SIGNATURE:                                                                                        MEDICATION:	Flamazine  cream 			PRESCRIBED DOSE: 	Start 24 hours after antibiotics, pain relief and e collar apply liberally three times daily for 14 days 	 Contact vet if skin deteriorates 	QUANTITY PRESCRIBED:	2	AUTHORISED REPEATS: 1		PRESCRIBING VETERINARIAN: 	Dr Jorid Nordaker V9034QUALIFICATIONS: 	BVSc MTch 		VETERINARIAN SIGNATURE:    Vital Signs    Weight: 9.1;