C09985183 / invoice 10000

Reason: check skin
History:
very irritated and been licking the ventral chest and scratching with RFL
licking at the RFL a bit as well
been licking at it for past 3 days

Medications: none
EDUF: normal
Mentation: BAR, very relaxed with daughter holding P today in consult, was able to examine P
BCS (0-5):   3/5
HR: 112
RR: 20
MM: pm                 
CRT: 1-2 sec
Temperature: NA
Dental Stage: ~1-2/4
Any additional findings:
~1cm dermatitis lesion on the ventral chest, close to R prescap region with alopecia 
moist around the lesion region as well
on the RFL noticed wet down fur but no skin lesion or alopecia noted so far

Assessment:
pruritus causing dermatitis lesion from overlicking

Treatment:
pred 5mg sid for 7d then wean off dose
cephalexin 100mg bid for 7d
ecollar for next 2 weeks

Plan: RV in 2 weeks. Discussed with O's sister-in-law today after finishing consult, P has been doing really well today and did discuss about dispensing anxiety meds for vet visits with Nigel (O) and whether if want to proceed with it, which sister-in-law said to do it in case if O's daughter is not present during RV. 

O booked appt for 5.30pm tonight, according to notes, was rec to have gaba and traz etc before coming, and contacted MO about it and rec dispensing now and O to give 2 h before coming, but MO said as he is currently at work so wont be able to get the meds now and O's daughter and O's sister in law will be brining P in today
noticed itching on the chest and has been chewing at it for past few days and causing her to be more clingy etc and irritated by it as well
mentioned to O w/out the anxiety meds poss may not be able to have a detailed exam and O aware. 
potentially starting on meds (pending on what we find during PE) and rec dispensing gaba and traz for O to give during RV instead, which MO consented for it over phone.

Reason: Vaccination
History: 
Presented by MO today 
No concerns to report 

EDUF: good 
V#/ D#/ Coughing? none 

Current medications: none - did not end up picking up gabapentin or trazodone, does not want these 

Examine: 
Mentation: BAR, highly anxious. Muzzled and taken to tx room. Limited exam performed due to temperament - urinated and defaecated midway through exam, ceased further attempts here 
BCS (0-5): 3/5        
MM:  muzzled                 CRT:
HR: 140                  RR: 40
Integumentary & lumps (measurement, location): good coat quality, no lesions noted 
Musculoskeletal: ambulatory

Assessment: 
- fit for vaccination 
- clinic-associated anxiety is a significant concern - was able to vaccinate and do partial exam today however Luna was so anxious she defaecated and urinated. Anxiety will likely only continue to escalate without treatment, and not pleasant for Luna to be this distressed so have advised pre-visit calmatives are strongly recommended in the future 

Vaccination given: C5
Batch number: DHPPi (2524002), BBO (2524002)
Annual vaccination needed: KC