C09989645 / invoice 10000

Routine booster and o wanted to discuss skin dx. On CE, BAR, given treats so tolerated well, ears eyes nose NAD, lns wnl, teeth NAD, heart and lung ausc NAD, abdo palp NAD, BCS:5/9- o dropped from 26kg, looking goodFeet very pink and areas that look moistO asked re boots adv againstGiven vacsUp to date with parasite treatment - ORLong discussion regarding allergiesDisc key causes: parasites/ food/ environmentR/O parasites as is on simparicaNext R/O food - disc diet trail for 6-8 weeks. Adv have to be very strict and disc no other treatsDisc use RC or PurinaIf not keen to do this disc apoquel vs other medsConcluded plan:Vaccines today so start apoquel on Mon - loading dose first and then maintenanceThen start hypoallergenic straight awayStart chlorhex bathsAfter 4 weeks of apoquel (+starting 5 days late today) - stop apoquel and see if pruritius recurrs up to the 6 week mark. If recurs, restart apoquel and repeat the same process at week 8 - happy for o to pick up another week of apoquel - will have to load again. Stop at week 7- monitor response by week 8If positive response can stay on HA long term or could add in single source proteins to see what triggers itIf no response when stop apoquel likely environment and can either continue with apoquel long term - adv bloods every year or can look at cytopoint/ other allergy treatmentsO happy with plan Will check in again after diet trailEmail sent to o to clarify plan:Hi!I just thought I would write you a time line of everything we discussed today.So start hypoallergenic today, start apoquel on Monday.After 4 weeks of apoquel stop and just keep on with the hypoallergenic.Between week 5-6, monitor the response to just the diet. If the itching re starts, re start the apoquel for 1 more week between week 6-7. I have authorised another week worth to be put up at a loading dose.Then at week 7-8 stop and monitor the response. If the diet has worked, there should be no itching and you can either continue with the hypoallergenic or you can add in single source proteins and monitor the response (eg. boiled chicken). If the diet has not worked and when on just the diet at 8 weeks, Louie is itching again, then lets have another consult to discusss whether we do apoquel long term or whether we consider cytopoint or other methods.I hope this all makes sense! Let me know if you have any questions.Best Wishes,Dr Poli BoynovaGreencross Fairy Meadow    Vital Signs    Weight: 22.65;       

Reason: Paws Have Flared Up Appointment Notes: the spray given last consult helped slightly but paws have since gotten worseObjective: Coat and skin: appear normalEyes: appear normalEars: appear normalNose and throat: appear normalMouth, teeth and gums: Appear normalLegs and paws: right front foot inflamed again red with some pus dischargeGait: appears normalHeart: Normal on auscultationLungs: Normal on auscultationAbdomen: Normal on palpation and auscultationGastrointestinal system: appears normalUrogenital system: Appears normalLaboratory:Assesment: dermatitis feet mainly right front footNormal physical examPlan:Cotnoineu cortavance ok to repeat largeer bottleKeep area cleana nd dryConsider bootiesTrial apoquel as well when itchy    Vital Signs    Weight: 26.2;       

Reason: Infection Between ToesPast week getting worseObjective: Coat and skin: appear normalEyes: appear normalEars: appear normalNose and throat: appear normalMouth, teeth and gums: Appear normalLegs and paws: appear dermatitis between toed front feet, mild pus dischargeGait: appears normalHeart: Normal on auscultationLungs: Normal on auscultationAbdomen: Normal on palpation and auscultationGastrointestinal system: appears normalUrogenital system: Appears normalLaboratory:Assesment: dermatitis feet, allegeisNormal physical examPlan:Keep feet clean, cortavance sid, ok to try isaderm +/- apoquel if not responding    Vital Signs    Weight: 26.5;