C09974792 / invoice 10000

HISTORY: History:
Anxious and scratching at face excessively all of a sudden. 
No V+ or D+. 
No fainting episodes. 
Does try to catch bees with mouth. 
No limping or lameness. No random yelping. 

Examination: 
CRT: < 2s      MM: pink      HR: 112     FP: normal, synchronous      RR: panting
CV: no murmur detected on auscultation; normal rhythm
Resp: normal bronchovesicular sounds; normal respiratory effort and pattern
GIT: soft and comfortable on abdominal palpation; no evidence of bee stinger in or around the mouth 
U/G: no discharge or pain or palpation of bladder
MSK: normal muscle conditioning and tone
Integ: moderate facial swelling, especially around muzzle; no evidence of hives 
Neuro: BAR; normal posture; normal mentation; ambulatory; no ataxia; no obvious CN deficits 
Ophth: clear; no discharge, cloudiness or other abnormalities noted
PLNs: normal consistency and size on palpation; no enlargement or asymmetry

Problem List:
- facial angiooedema 
- pruritis 

Assessment:
Allergic reaction (ddx: bee sting) 

Plan:  
Chloraphniramine 1.41 ml SC. 
Dexamethasone 1.41 ml SC. 
Looked for bee sting, could not find one

Communication:  
Any V+ or fainting, RV immediately.
WEIGHT: 28.20

WEIGHT: 28.10

HISTORY: Behavioural issues. Biting people - bit a man on his bottom yesterday on a walk. Nipped a childs leg at a cafe. Very boisterous too - owner is having difficulty with him. He is a rescue - had a rough upbringing accourding to owner. Owner has his bloods checked for hypoT - T3 and T4 levels normal. No other abnormalities noted on his blood work. Owner has had trainers come to the home to offer help but nothing has worked. 
He also has an ear infection. 

PE - BAR, EENM nad, teeth excellent, MM pigmented, BCS 4.5/9. 
Demeanour - nervous/excitement, confident and high drive. 
Right ear mild otitis externa - cytology: ++ cocci, + yeast. 

C - 
Discussed obedience training - suggested alpha training to help provide structure and control. 
Advised as much mental stimulation and environmental enrichment as possible - this dog needs to exert himself
Discussed the use of muzzles in public places - basket muzzle to be specific - too help owners anxiety primarily and to avoid anyone getting hurt. 
Discussed avoidance of situation where he feels the need to bite. 
Discussed CBD. Discussed SSRIs. 

Owner elected to try fluoxetine. Start at low dose and then adjust if needed. Wait 2-3 weeks to see full effect.