C09971101 / invoice 10000

********CONSULT********
Date/Time: 01/03/26 1915hrs 
Clinician: TC 
HISTORY: 
Is on cytopoint for his allergies + is on pentosan injections, was given one dose of prednisolone + chlorpheniramine at the same times a cytopoint-  this is to reduce acute itching. 

Owners have noticed a rash under his armpit tonight. Doesnt seem too itchy 

Eating and drinking normally 
Urinating and defecating without issue 
Was given meloxicam Friday and Saturday night for limping/OA - owner gives this intermittently -- NB 


Prev health concerns: 
- an episode of lethargy 04/01/18
- allergies (atopy) treated with a short course of pred, neocort and ceph for secondary skin infection 14/02/18
- GIT upset 04/09/18 and again on 31/01/19 
- eye ulcer treated 2021, 2022 and 2023 


PHYSICAL EXAM: 
Weight: 16.8kg
Temp: unable to take 
CardioV: HR: 104 , sounds: normal , rhythm  normal , CRT <2sec, MM: pink 
Resp: RR: pant  , sounds: normal for breed , effort:   normal 
Neuro:  BAR 
GIT:  NSF 
Urinary: NSF 
Musculoskel: NSF  
Integument: very mild erythema left axilla associated with 3 small lumps- one on the medial aspect of arm, the others in the axilla itself. Leo doesnt seem bothered and does not resent palpation of the lumps, all are small <0.5cm 
Ears:  NSF 
Eyes:  clear/ NSF 
LNs:  NSF 
Otherwise NSF : 


PROBLEM LIST, ASSESSMENT + PLAN: 
hx of allergies - cytopoint, antihistamines and occaisional dose of pred 
hx of OA- pentosan and occaisional dose of meloxicam 
hx of eye ulcers and senstive gut 
today is presenting for 3 small lumps under left axilla. Ddx: mild allergic reaction vs early stages of pustular rash/ mild pore infection, neoplasia cannot be ruled out without biopsy


CLIENT COMMS + PLAN: 
Discussed case with owner, explained that a biopsy would be required in order to diagnose what these lumps are- they do not seem to be bothering Leo. Owner has requested neocort cream, explained that I did not feel that he required it but would be an alernative to a steroid injection (cannot given as has recently been administered meloxicam). 
Offered neocort cream + a an antihistamine injection, owner declined antihistamine injection and consented to neocort cream. Dispensed this and emphasised only to use for 3 days and not to allow Leo to ingest the cream. Owner has had experience using neocort cream before. 
Recommended presentation to RV for biopsy if lumps did not disappear as cannot rule out neoplasia (owner is concerned for neoplasia- requires GA and biopsy, lumps are too small to FNA) 

NB: discussed the danger of concurrent meloxicam and prednisolone use (owner has both at home to use PRN- have cautioned to be very careful never to administer both at the same time and to seek veterinary direction when administering both. 

DATE/TIME of CONSULTATION: 20:03hrs, Sat 29/07/23
CLINICIAN:  CL

PRESENTING COMPLAINT: possibly ulcer

HISTORY:
- squinting in the right eye today
- went for a walk and was putting his head in bushes
- not currently on any medications but has just finished a course of pentosan injs
- o put chlorsig in this morning
- has had several corneal ulcers in the past

CLINICAL FINDINGS:
BAR soooo EXCITED!
quite difficult to restrain for exam
hr 160 bpm  pink crt < 2sec
panting, normal stertor for breed
abdo palp normal
mild blepharospasm R eye 
BCS 5/9

DIAGNOSIS:
R eye corneal ulcer

TREATMENT:
alcaine and fluorescein applied to right eye
can see a 3mm comma shaped corneal ulcer over the ventro lateral aspect of the cornea 
unable to properly assess for FB, ectopic cilia, kcs etc as too excited
cotton tip used to debride ulcer edges 

o already has chlorsig and meloxicam 1mg tablets at home
to administered meloxicam 1.5mg sid with food for 5 days and chlorsig TID for 7-10 days

CLIENT COMMUNICATION/PLAN:
advised to wear e collar to protect eye from further self trauma but owner declined
rv with regular vet in 5 days