C09982054 / invoice 10000

poss bloods recheck after antibiotics
no se's from ab's
still mod itchy, minimal improvement on cephalexin - rubs ears on ground, perianal pruritus, tummy (commando crawls)
onset 6mths ago
nexgard monthly + allwormer 3mthly
no GI signs
thinks well in herself
other dog (patients genetic brother) was in care of dermatology before he passed (hypoT), no humans itchy
no change in enviro or diet

CARE - o warns not handleable, hes not confident even lifting her lip or touching her ears
usually comes in on calmatives but has run out so none administered for todays appt

handled by nurse, muzzled then covered eyes with towel - much better but still reactive for exam so did minimal today
both ears thickened, inflammed and discharge, otoscopic exam not attempted
ventrum - lichenified, hyperpigmented
alopecia and hyperpigmentation along medial thighs and perineal region but cant examine
cant examine paws, look normal from a distance
chest ausc nad

cytology
ears: yeast ~6-7/hpf
skin: admittedly not a great sample, only 1-2 yeast seen over whole slide but no cocci seen

OE
pruritus
malassezia dermatitis?

enro/ dex/ ketoconazole poloxymer gel 1ml instilled into each ear
o can use malaseb bath twice this week but must ensure no water in ears
RV 7 days WITH A VET while on gabapentin and trazodone
- assess response to apoquel, consider pred if needed
- second dose of poloxymer gel into each ear - COVER EYES FOR THIS, MUCH CALMER
- attempt sticky tape sample of skin to assess for malassezia and start fluconazole if needed
- if inadequate sedation can increase gaba/traz dose for next RV in a further 7 days fasted and in the morning for sedation and work up (thorough PE inc AG expression, skin scrapes, smears, otoscopic exam, bloods for CP2 and T4 to vetnostics then can upgrade to full thyroid panel if needed- delay bloods if feel unwell or infection not adequately controlled and will affect results)