C09989254 / invoice 10000

Reason: Irritation Behind EarDiscussion with the owner 21:04-21:15History:Presenting complaint is a new skin lesion, first noted on Sunday. The patient was taken here on Sunday by owner's daughter but went home with only an e-collar as wait time was too long.  Daughter never told owner Luna needed to be seen by the regular vet the next day. The owner is concerned by the lesion's appearance. The owner has been using a cone for the last two days to prevent scratching, although the patient is not reported to be actively trying to scratch the area and is not appearing overtly itchy. The patient is reported to be sleeping more but is otherwise acting normally on walks, eating well, and not seeming sad or lethargic.The skin issue started after the patient got wet at a dog park. The owner gave a shower but did not dry the coat completely. This is the first time the patient has had a skin issue.Reg vet: Dundas Vet.BIOP, other pets: Since 8 weeks of age. No other pets mentioned.Indoor/outdoor: Taken for walks, including to the dog park.Normal diet and treats: Cooked food mixed with dog food.Vacc and preventatives: Fully vaccinated. Receives regular worming, including for blood worms.Previous medical history: Hip and knee operations performed at a specialist hospital. The hip operation was at approximately 8 months of age, and the knee operation was about a year later.Current medications:The owner attempted to use a product containing zinc oxide for itchiness, but the patient refused it.*MENT: BAR and nervous, constantly barking. Calms down when patted but still on edge. *HYDR: Seems euhydrated.*TEMP: 38.8C. *OCU/AURAL: Eyes and ears clear.*ORAL: Full oral exam not performed due to demeanour and muzzle, visual inspection during panting grade 1 dental.*C/V: Mucous membranes pink and moist, CRT 1 second. HR 120 bpm, no murmur or arrhythmia. Excellent, synchronous peripheral pulses.*RESP: Panting. No overt bronchovesicular sounds, normal effort, no cough/sneeze witnessed.*GI: Soft, doughy abdomen, no pain elicited, no obvious mass effect.*UROGEN: Normal vulva, clean perineal area. *L/N: Palpable peripheral lymph nodes within normal limits.*INTEG: Good coat otherwise except alopecic area underneath the right ear and continuing slightly dorsally into the crease and to the skin of the external ear. Lesion had dried discharge and was actively discharging a little bit (on the tape sample). Erythematous but doesn't feel thickened compared to the surrounding skin.*MUSC/SKELE: Normal gait, no obvious abnormalities*NEURO: Alert and responsive. Normal proprioception. Unable to perform cranial nerve examination due to demeanour. *RECT: Not performed.Assessment:- Moist dermatitis (hotspot): clinical appearance, history of getting wet and not being dried properly. Most likely still relatively superficial. Concerns about the skin lesion were discussed with the owner, and options for diagnosis and treatment were provided.Tentative Diagnosis:Moist pyotraumatic dermatitis (hotspot). The history of the fur getting wet followed by the rapid appearance of a raw, inflamed skin lesion is characteristic.Plan: suggested1. Cytology from the skin lesion with acetate tape2. Empirical treatment for a hotspot without diagnostics.Plan: actual, agreed by the owner1. Cytology of the skin lesion.Client communication:Discussed the likely diagnosis of a hotspot, explaining how they typically occur when the skin gets wet and isn't dried properly, especially in humid and hot weather, leading to bacterial overgrowth. Mentioned that the hair falls out and the area can be painful and itchy.The owner opted to proceed with the cytology to determine the cause of the lesion.Explained the results of the test. Discussed different treatment options in terms of antibiotics. Opted for amoxyclav despite being possibly too broad spectrum as is a smaller tablet and easier to give than cephalexin. Educated owner about the risks of steroids and side effects. Discussed that might need a longer course in case not enough so should get in contact with us or the regular vet at the end of the course if not fully dried up. Sent to reg vet: yes    Vital Signs    

Reason: Injury Behind Ear    Vital Signs