C09988517 / invoice 10000

History
-   Diet:
-   Presenting Complaint: Acute onset severe pruritus behind the AS. Lethargy for the past few days.
-   Parasite Prevention: UYTD nexgard spectra
-   Health Problems: Motion sickness.
-   Other History:

Current medications
-   Current Medications: cerenia when needs for motion sickness

Examination
-   Temperature:
-   HR: 132
-   Thoracic Auscultation:nad
-   Abdominal Palpation:nad
-   Oral Cavity/Dentition:good
-   Ears: Ear canals are clear.
-   Eyes:a little red around L eye
-   Coat/Skin: A 10 cm patch of erythemic, pruritic skin (hot spot) is present behind the AS. The area has been clipped and cleaned. The coat is ungroomed.
-   Musculoskeletal (MSK):
-   Behaviour: mildly Lethargic.
-   BCS (BCS): 5/9

Assessment and pertinent findings
-   Assessment: Acute moist dermatitis (hot spot).
-   Differential Diagnoses: other acute allergy
-   Recommended Workup: Cytology performed, results are pending.

Treatment and plan
-   Treatments/Medications:
    -   Neocort cream applied to the affected area twice a day for 4-5 days.
    -   Pyohex spot washes of the area.
    -   Prednisolone 2.5 mg once a day for 3 days, then q other day for up to 5 days.
-   Follow-up: Recheck in 5 days. Grooming is recommended after the recheck.
-

"doing alright". O has been monitoring - less energy first day but yesterday afternoon energy levels normalised
No other symptoms 
Confirmed no more vomiting and eating fine. Giving small bland meals, improved appetite. 
Said glad to hear he's feeling better and to call if any changes.
AZ