C09985988 / invoice 10000

Presented for: skin flare. 
See previous. Still receiving SID apoquel which has controlled itch for the most part. Current diet Prime duck roll, no change to diet. 
Still EDUF Normally. No V+/D+
Itching at belly, feet + cranial HLs and ears. 

BAR MM pink. CRT <2sec. 
All vitals WNL. 
Mild erythema ventrum, early papular rash cranial HLs. 
Both ears mildly erythemic, clear canals, some waxy discharge R>L. Cyto - scant malassezia bilaterally. 

Increase apoquel to BID for 7d and reduce. Inj dex for immediate itch relief. 
Repeat script written for elocon lotion. Use once/twice weekly for maintenence. 

Reason follow up 

18/1/26 STORY: Pochita presented for possible aspiration pneumonia. She went for walk at
5:00 pm yesterday in 26 degree weather which is abnormally hot for her (normally not
walked when this warm). Upon returning home, experienced approximately six watery
vomits until 6:30 pm. After the last vomit, she developed coughing and 'collapsed' into
lateral recumbency whilst inside the house, minimally responsive for approximately 15
seconds before recovering. Owner unsure about gum colour during episode. No seizure
activity or twitching observed. Prior to incident, eating, drinking, urinating and defecating
normally

Was discharged from PVE with maropitant and amoxyclav. 

Pochita has improved at home, is bright alert, EDUFBAR tolerates play well as well. Does still cough mainly after waking up after a big sleep. but not throughout the day. 

Vitals: HR=PR= 120, OMM pink, moist, CRT 1-2 sec, RR 24, Temp 38.1   skin turgor ~ 1 s.
CVS:   no arrythmia or murmur auscultated  Resp:  normal bronchoalveolar sounds, only harsh lung sounds over trachea heard. 
ABDO SKIN MSK unremarkable. 

Client comms: no signs of pneumonia noted. intermittent infrequent cough can be treated with cough suppressants if its excessive. or can try honey and water. 
discussed with owner to monitor for perfusion parameters and RR at rest. O happy with plan. can recheck at the end of amoxyclav course. 
O would like more apoquel as well. Ok to dispense more for on going use 

Recheck skin
O can't afford rx (Insurance company becoming too expensive and not supportive)  and finding the travel to Derm too awkward.
Cannot use cortavance spray - it makes her feet worse/itchy/painful
Can only give Apoquel chewable as she won;t take plain ones in anything - current dosage 5.4mg sid and she is starting to lose hair coat, develop light papules through the coat.bathing weekly in Pyohex, applying pyohex conditioner.
Elocon in ears is working well.

Ex: QAR, BCS 5/9 coat appears full if a little thin, M p&m crt<2sec, HR 120, regular, no murmur.
a few small papules in shoulder skin

Dx: Needs increased apoquel to keep confition under control - rec BID administration for 2 weeks then reduce
For cost savings, can cut down 16mg tablet to 1/3's and use this - will reduce cost significantly
Continue with bathing ans hexaspray

Advise O we do not routinely stock apoquel as chewies, so will be a special order - please advise before she runs out if repeat script is needed

O has prepaid Apoquel