C09976651 / invoice 10000

GAP ONLY HISTORYFirst clinical signs - Constantly licking at the left elbow regionSummary - Focal dermatitis at the left elbow region, has been improving todayDiagnosis - Focal hot spot at the left elbow regionTreatment - Neocort topical treatment for 3-5 daysReason: Keeps Licking Leg - NBDiet: Recent changes to diet: nil #Preventative healthcare:Vacc:HWP:IW:Flea/tick:HISTORY:O's presenting complaint(s): When were the clinical signs first observed?(including age of onset, <3years is typical for atopic dermatitis)Have they progressed, remained stable, or improved?Seasonal incidence?Appetite: Normal #Thirst: Normal #Vomiting: Nil #Diarrhoea: Nil #Current medications: Nil ##Previous medical history: Nil relevant ##Examine:PHYSICAL EXAMINATION: Mentation: alert and responsiveBCS: ## / 9MCS: normal muscle mass #EYES: NAD - clear, no noted discharge #EARS:Left ear:Canal - clear, no discharge, odour, erythema#Pinnae - clear, no lesions, odour or erythema#Otoscope exam - clear, no foreign bodies identified. Tympanic membrane visualised intact / not able to be visualised on conscious exam #Right ear:Canal - clear, no discharge, odour, erythema#Pinnae - clear, no lesions, odour or erythema#Otoscope exam - clear, no foreign bodies identified. Tympanic membrane visualised intact / not able to be visualised on conscious exam #NOSE: NAD - clear, no discharge, symmetrical, no lesions #ORAL: NAD - normal pink and moist mm, normal CRT, healthy teeth & gums#CARDIOVASCULAR - NAD - no murmur or arrhythmia auscultated, pulse pressures normal and synchronous#RESPIRATORY: NAD - thoracic auscultation clear sounds bilaterally, respiratory effort normal#ABDOMINAL: NAD - soft pliable, no detectable pain or palpable abnormalities#NEURO: NAD - neurologically no significant findings, no cranial nerve or proprioceptive deficits/gait#MUSCULOSKELETAL: NAD - ambulating with normal gait & posture, no pain on palpation of joints, appropriate ROM#RECTAL: not performed#REPRODUCTIVE: externally normal #INTEGUMENT: Coat condition:Erythema: Nil #Alopecia: Nil #Skin lesions (eg papules, crusts, erosions, excorations, lichenification): Nil #Distribution of lesions: NA #Parasites: Nil visualised #Lumps: Nil #LYMPH NODES: NAD - peripheral nodes palpate normal #Assessment:Problem List:1.DdxTests and Results:Tape cytology: Skin scraping:Woods lamp:Treatment:Plan:Short term (acute) plan:Long term plan:Revisit in 2 weeks to discuss and implement a long term skin management plan--- 03/03/2026 08:50:32 AX:Worming - Skipped on 12/12/2025Verified: NoSubjective:Diet: Taste of the Wild salmon/fish formula - chicken removed from diet due to ear infectionsRecent changes to diet: nil #Preventative healthcare:Vacc: HWP: IW: 3 monthly tablet administered recently - up to dateFlea/tick: HISTORY:O's presenting complaint/s: Licking top of right leg with development of lump, noticed Saturday morning- Licking behaviour started Saturday, worse over weekend- Lump developed from licking behaviour- Improved yesterday with minimal licking, slight licking this morning- Owner suspects hot spot similar to previous poodle- Dog sleeps in crate, evidence of overnight licking- Also concerned about dirty appearance under stomach despite bathing- History of multiple ear infections until July, now managed by plucking ear hair nightlyAppetite: NormalThirst: NormalVomiting: NilDiarrhoea: NilAccess to chemicals or toxins: Nil knownAccess to rodenticides: Nil knownCurrent medications: Prednisolone liquid discontinued approximately 1 month agoPrevious medical history: Multiple recurrent ear infections until July - managed by avoiding ear plucking and nightly hair removal- Uses Aloveen shampoo- Groomed every 6 weeks with owner bathing once or twice between visits- 3 year old dog with history suggestive of atopic dermatitisExamine:PHYSICAL EXAMINATION:Mentation: alert and responsiveEYES: NAD - clear, no noted dischargeEARS: hairy ear canals, no current infection notedNOSE: NAD - clear, no discharge, symmetrical, no lesionsORAL: NAD - normal pink and moist mm, normal CRT, healthy teeth & gumsCARDIOVASCULAR - NAD - no murmur or arrhythmia auscultated, pulse pressures normal and synchronousRESPIRATORY: NAD - thoracic auscultation clear sounds bilaterally, respiratory effort normalABDOMINAL: NAD - soft pliable, no detectable pain or palpable abnormalitiesNEURO: NAD - neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMUSCULOSKELETAL: NAD - ambulating with normal gait & posture, no pain on palpation of joints, appropriate ROMRECTAL: not performedREPRODUCTIVE: externally normalINTEGUMENT: focal lesion right forelimb consistent with hot spot, improved from weekend presentation - less red and smaller, hyperpigmented areas on ventral abdomen and around nipples consistent with chronic irritation, small scab noted possibly from clipper traumaLYMPH NODES: NAD - peripheral nodes palpate normalAssessment:Problem List:- Hot spot right forelimb - improving- Possible clipper rash- Chronic dermatitis with hyperpigmentation consistent with atopic dermatitis- History of recurrent otitis externaTreatment:Neocort dispensedPlan:- Apply Neocort thin layer to affected area twice daily for 3-5 days- Continue use of inflatable collar to prevent licking- Monitor for improvement- Continue current bathing routine with Aloveen- If pruritus becomes generalized, consider short course Prednisolone- Recheck if no improvement or worsening- Continue current ear management routineGAP ONLY HISTORYFirst clinical signs - Summary - Diagnosis - Treatment -    Vital Signs