C09976554 / invoice 10000

ARRIVAL TIME:SIGNALMENT: 4-year-3-month-old male neutered LabradoodleHistory Summary:Presents for acute onset skin irritation. Owner noticed red spots on the abdomen and prepuce today. The patient has been licking the area and is pruritic. Has been restless and unsettled for the past 3-4 days. No vomiting or diarrhoea. Appetite is normal. Owner has administered an antihistamine and used a chlorhexidine-based wash. Potential contact with an unknown irritant in another person's car or in the yard after rain. No other new dietary or environmental changes noted.TRIAGE:HR: 104 bpmRR: 32 brpmTemp: 39.2°CMM: Pink & moistCRT: < 2 secondsMentation: Bright, Alert, ResponsivePain Scale (MGCS): 0Hydration status (%): EuhydratedEXAMINATION:Body Condition Score: 4/9Cardiovascular: Cardiac auscultation normal, no murmur detected, pulse pressures normal and synchronous.Respiratory: Thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal discharge.Neurological: Neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMusculoskeletal: Ambulating normally, no apparent neck, spine, limb or joint painGastrointestinal:Oral: NSFAbdominal: Soft, non-painful. Erythematous rash present on the ventral abdomen.Rectal: Normal, no diarrhoea, normal faeces Urinary: NSFReproductive (incl ext genitalia): Erythematous rash noted on the prepuce.Integumentary system: Generalised erythematous macular rash, most prominent on the ventral abdomen and preputial region, but also present diffusely under the axillary regions bilaterally and inguinal regions bilaterally. Some spread up to the sternal region and milder region around peripheral ears. Lymph Nodes: WNL on palpationEyes: NSFPROBLEM LIST:1. Acute pruritus and erythematous rash2. Mild pyrexiaDIFFERENTIAL DIAGNOSIS:Allergic reaction/hypersensitivity: Contact dermatitis (e.g., grass, plants) or systemic reaction (e.g., insect bite, food). This is considered most likely given the clinical signs.Urticaria.Insect bites (e.g., ants, bees).Pyoderma (early).Petechiae secondary to coagulopathy or platelet disorder: Considered less likely as the lesions appear erythematous rather than purple, along with additional history and symptoms of pruritis and flaking.DIAGNOSTICS/MANAGEMENT PLANProposing treatment for presumptive allergic reaction. Discussed starting steroid tablets, antihistamine tablets, and a topical cream (Neocort). If no improvement, further diagnostics such as allergy testing or referral to a dermatologist may be required.REVISED ASSESSMENT:Suspected allergic reaction/hypersensitivity.PATIENT UPDATE:Stable/Improved: StableE/D/D/U/V: Eating and drinking normally, no vomiting or diarrhoea.TREATMENT SUMMARY:Prednisolone 20mg Tapering course from 0.8mg/kg --> 0.5mg/kg PO SID over 4 days. Iramine 8mg q8-12 PO Neocort applied topically SID to affected areasE-collar application (owners have at home)OWNER COMMUNICATION:Discussed the likely diagnosis of an allergic reaction. Explained the treatment plan involving oral tablets (steroid and antihistamine) and a topical cream containing a steroid, antibiotic, and local anaesthetic. Advised owner to wear gloves when applying the cream. Advised to apply the cream once daily for approximately one week. Recommended a recheck with their regular veterinarian in 3-5 days to monitor progress. Explained that if the condition worsens or does not resolve, further investigation would be necessary. The owner was provided with discharge instructions.PLAN:Discharge home with prescribed medications. Monitor for improvement in pruritus and resolution of rash. Follow-up with regular veterinarian in 3-5 days or sooner if concerned/if worsening symptoms arise. For any questions regarding the case, please contact the Underwood and Jindalee Clinical Support Line at 07 3147 8746 (Mon-Fri, 9am-6pm), or our hospitals during after hours.    Vital Signs