C09984797 / invoice 10000

04/03/2026 Primary Presenting Complaint - goes to beach every day, o thought maybe bee sting. L axilla rash. check teeth. Focal dermatitis/skin irritation under arm with progressive worsening 
Other Complaint - Overweight body condition, dental disease, anxiety during vet visits
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History - Lesion present for several days, initially treated with loratadine without improvement. Owner has been administering chlorpheniramine at night. Dog has history of anxiety at veterinary clinic.
         Last Normal - eduf norm 
         Frequency   - Increased licking and scratching particularly at night
         Last Ate       -
         Medicine Hx  - polaramine
         Diet              -
         Vacc Current -
         Worming Hx  -
         Heartworm    -
         Microchip       -  Y / N    -  scanned - ok?

Examination:
Overweight dog presenting with focal allergic dermatitis/urticaria and self-trauma, otherwise systemically well

    - Attitude - BAR at home, anxious during examination
    - Body Score - Elevated BCS 7/10
    - Hydration status - wnl
    - Temperature - N/A
    - Heart - ~100 HR. Murmur - nil
    - RR - wnl
    - Dental - Score(0-4)= G1, teeth well maintained, very mild calculous over 104 & 204 
    - CRT - immediate
    - Eyes - NVL
    - Ears - clean and discharge free
    - Abd Palpation - Unremarkable
    - Gastrointestinal - No Sig Findings
    - Urogenital - No Sig Findings
    - Skin - Focal axillary dermatitis with multiple pinpoint urticarial lesions, erythema, secondary excoriation from self-trauma. Evidence of licking and scratching.
    - Musculoskeletal - No Sig Findings
    - Neurological - No Sig Findings
    - Lymphatic - No Sig Findings
    - Other Key Findings - 

Assessment:
Allergic dermatitis (likely contact or atopic) with secondary self-trauma and possible secondary bacterial infection

Problem List:
1. Focal axillary allergic dermatitis with urticarial lesions
2. Secondary self-trauma from excessive licking/scratching
3. Overweight body condition
4. Dental disease

DDx:
DDx for dermatitis: Contact hypersensitivity, atopic dermatitis, insect bite hypersensitivity reaction, less likely foreign body reaction or parasitic migration given presentation of multiple pinpoint lesions rather than single focal area

Discussed:
Owner consented to treatment plan. Discussed importance of barrier protection (recovery suit or t-shirt) to prevent continued self-trauma and maintain inflammatory response. Explained that preventing access to lesion critical for resolution. Owner expressed concern about compliance with barrier protection due to dog's temperament but agreed to attempt. Discussed weight management and need to reduce caloric intake including any supplements. Owner informed treatment course should be short (few days) with expected rapid improvement. Advised to return PRN if condition worsens or fails to improve.

Treatment Plan:
Short course oral corticosteroids to reduce inflammation and pruritus - prednisolone 2.5mg. Topical cream application to affected area - neocourt. Barrier protection via recovery suit or t-shirt to prevent self-trauma. Weight management through caloric restriction.

Ongoing Prescriptions:
Collagen supplements (owner-administered)

Next Visit:
Return PRN if worsening or no improvement within a few days

The above clinical notes were created with the assistance of Astro Scribe under the supervision of the consulting Vet.