C09988257 / invoice 10000

Reason: Foot Issue And Was Advised Need Cytopoint InjectionRecord Entered by: Rachel Lee (DVM4) Record Checked by: BIOSECURITY STATUS: White  PRESENTING COMPLAINT: Bella is a 3 year old Female spayed Labrador presented for food issue and discussion about need for cytopoint injection.HISTORY: SPECIFIC HISTORY:Right front paw issue- Biting and licking, small open wound noted by the dog daycare => advised O to visit the vet- O is interested in topical options such as Neocort cream to reduce discomfortPrevious visit history:- Chronic allergic skin disease; suspected atopic dermatitis - recurrent ear infections (Malassezia otitis externa), Pruritus affeecting ears, paws and peri-ocular region. Periodic treatment with Cytopoint injections  NON-SPECIFIC HISTORY: LIFESTYLE: Mostly indoors; attends dog daycare regularlyBEHAVIOUR ISSUES: none reported  OTHER PETS: none  DIET: Dry kibble with home-cooked chickenCURRENT OR RECENT MEDICATIONS:- Cytopoint injection once a month for pruritus control- Recent ear treatment with Neptra for otitis externa (yesterday; 03.03.2026) APPETITE,THIRST,COUGHING ETC: - EDDU all normal and consistent. - No coughing or sneezing, vomiting or diarrhoea VACCINATION: up to date PARASITE PREVENTION (incl. Compliance): up to date  PHYSICAL EXAMINATION:WEIGHT: 32.8 kgFAS SCORE  /5: 1/5MENTATION: BARHR: 84PULSE QUALITY: strong, synchronousRR: 24TEMPERATURE: Not takenINTEGUMENT: No lesions or parasites. Mild focal alopecia on flexion parts especially near shoulder.CIRCULATORY: MM pink and moist, CRT <2sec, no heart murmurs or arrhythmias, femoral pulses strong and synchronous. RESPIRATORY: No wheezing or crackles, normal bronchovesicular sounds bilaterally.DIGESTIVE: No palpable abnormalities on superficial or deep palpation of the abdomen. Comfortable on palpation.Oral Cavity: No obvious findings.GENITOURINARY: No discharges from vulva. Desexed animal. Bladder small and comfortable, kidney palpation unremarkable.MUSCULOSKELETAL: No lameness or ataxia appreciated. Full MSK exam not performed. NEURAL: Normal, appropriate mentation, full neuro exam not performed. LYMPH NODES: Submandibular, prescapular, inguinal and popliteal lymph nodes symmetrical and normal size and consistencyEYES: Both visual, corneas transparent, no blepharospasm or epiphora. Mild gunk with itchiness (seen by vet related to this problem yesterday; not concern for today)EARS: Responds to auditory stimulus. BODY CONDITION SCORE: 6/9 IN-HOUSE DIAGNOSTICS: N/A  ASSESSMENT:Problem list:1. Interdigital dermatitisGiven Bella's history of presumptive atopic dermatitis with pruritus, this presentation is most consistent with an allergic flare causing pododermatitis. There were no signs of deep infection, lameness or systemic illness at this time.Overall, Bella appears systemically healthy with mild focal dermatological lesion secondary to allergic dermatitis, currently managed with Cytopoint for pruritus control. Topical neocort cream will addrress local inflammation and prevent secondary infection for pododermatitis. TREATMENT:- Cytopoint injection (40 mg/mL) 1 mL vial given- Neocort cream applied in consult - dispensed to be used by the OPLAN (incl. alternative options):1. Due to another cytopoint injection next month.2. Neocort cream: apply once every day for the next couple of days to front paws.Communication to O:- Neocort: mentioned to O that it includes steroid, local anaesthetics and antibiotics => not to lick cream as it contains steroid; O questioned whether it is toxic if ingested. Mentioned that while it is not toxic, it is still the best to avoid licking on it.- Mentioned to O about wearing cone for at least 30 minutes to 1 hour once the cream applied - Briefly looked at eyes and not concern at this point.Cytopoint - Injection site: Interscapular SC - Batch: 836645- Expiry: 02/2027    Vital Signs    

Reason: Eye Issues Record Entered by: Vet student ---- Brian TO Record Checked by: AED N8707 BIOSECURITY STATUS: White  PRESENTING COMPLAINT: check up of eye issue HISTORY: SPECIFIC HISTORY: Bella was presented today for check up of an eye issue. The owner brought Bella to doggie daycare yesterday, and the daycare staff advised the owner to bring Bella to a vet to check her eyes. The daycare staff however did not tell the owner what is their concern of the eye. The owner did not any discharge or other abnormality of the eyes. Bella also has a history of ongoing atopic dermatitis and ear infection, which is currently managed with cytopoint injection and ear drops. The owner mentioned that the effect of Cytpoint started to wear off over the last week and Bella was scratching her face occasionally. The owner mentioned that they would like to get to the underlying cause of the allergy, rather than coming back every month for cytopoint injection  NON-SPECIFIC HISTORY: LIFESTYLE: Indoor/Outdoor/Indoor & Outdoor: Mostly indoor BEHAVIOUR ISSUES: At Vet/At Home. None  OTHER PETS: None  DIET: Dry food with home-cooked chicken CURRENT OR RECENT MEDICATIONS: None APPETITE,THIRST,COUGHING ETC: EDDU all normal and consistent. No coughing or sneezing, vomiting or diarrhoea VACCINATION: UTDPARASITE PREVENTION (incl. Compliance): UTD PHYSICAL EXAMINATION:WEIGHT:                                              32.8 kg FAS SCORE                                         1/5:MENTATION:                                         BAR HR:                                                     	84PULSE QUALITY:                            	strong, synchronousRR:                                                     	20TEMPERATURE:            	            ---INTEGUMENT:   Fur sparse periorbital areas, remainder skin okCIRCULATORY: MM pink and moist, CRT <2sec, no heart murmurs or arrhythmias, femoral pulses strong and synchronous. RESPIRATORY: No wheezing or crackles, normal bronchovesicular sounds bilaterally.DIGESTIVE: No palpable abnormalities on superficial or deep palpation of the abdomen. Comfortable on palpation.Oral Cavity: Grade 1/4 dental disease, calculusGENITOURINARY: No discharges from prepuce/vulva. Desexed animal. Bladder small and comfortable, kidney palpation unremarkable.MUSCULOSKELETAL:  No lameness or ataxia appreciated. Full MSK exam not performed. NEURAL:                      Normal, appropriate mentation, full neuro exam not performed. LYMPH NODES:           Lymph nodes symmetrical and normal size and consistencyEYES:                          Both visual, corneas transparent, no blepharospasm or epiphora EARS:                          Moderate erythema and thickening of both pinna. Noted lichenification to base of LEFT ear pinnna and canal and markedly inflamed, Moderate amount of brownish discharge from both ear canals  BODY CONDITION SCORE:        	7/9 IN-HOUSE DIAGNOSTICS: ear swab sample taken from both ears - Heavy build up of yeast (malazessia) in both L and R ear (> 8 PHF),  minimal bacterial/WBC ASSESSMENT:Problem list:1. Chronic fungal Otitis externa  - secondary to atopy2. Mild epiphora and periorbital puritis (likely allergic, less likely infectious/bacterial conjunctavitis), secondary to atopy3. Overweight Include your clinical impression of the animal: Bella was bright, alert and responsive. She is calm and easy for examination. The recurring ear infection and ongoing pruritus is more likely to be caused by underlying allergic reaction. Most common causes of allergic response in dog include environmental allergens (pollen, dust mites etc), food allergy and ectoparasites. Owner is advised to booked in for a dermatology consult for a better long term managment plan of the skin condition.  TREATMENT:- Cleaned deep ear canals with epiotic- Neptra ear ointment applied to per ear canal of both ears. Discussion with O - O keen to get to root course of atopy (food/environment/ectoparasites), rather than treating the symptoms with cytopoint, brief disc re derm referral Beth McD- ideally consider food/Novel protein diet trial (O to consdier)PLAN (incl. alternative options):1. Owner is advised not to clean or wash Bella's ear for 4 weeks for application of Neptra ointment 2. Owner is advised to give 1.0 tablet of antihistamine twice daily for 4 week 3. Discussed about Dermatologist referral with the owner. :    Vital Signs