C09992610 / invoice 10000

PROBLEM LIST:Bacterial folliculitis Yeast infection (right ear) Suspected underlying allergy Overweight HISTORY:Since the last consultation Bronny has received the following treatments:Malaseb Shampoo 250ml Rx: Apply rich lather to the feet twice weekly for the next week leaving on skin for 10 minutes before rinsing well. Towel dry then apply the Pyohex conditioner. Medications Dispensed: 42.00 x Clindamycin 150mg tab Rx: Give 1.5 Tablets (ONE AND A HALF) morning and night until late January.Easotic Ear Suspension For Dogs 10ml Rx: Instill 1 (ONE) Pump into each ear daily for 5 days. Pyohex Medicated Conditioner 200ml Rx: Apply to lesional areas after bathing.He is  fed Hills Anallergenic . The crusts resolvedThen relapsed the last 10 days. itching of the ears and perianal are then perianal area and left hind foot. PHYSICAL EXAMINATION: so if you look carefully there is some localised crusting on the right side of the neck and on the right side of the flank the hair coat remains dull and dry there is been no greaser regrowth of hair on the area previously clipped two months ago there is slight volar erythema on the left forefoot is mild volar erythema the left hind foot six there is some crusting to my desk is a bit of peace left ear but let me clipped a flareup could go Dodge be carefully as if I Trevor O'Neill know about the problem with being very it's a bit messy around bottom and we have had a ear hair has grown back since the last one since this area and a dry workout ear there is some scab on the bottom as well see the scab thereunder the hair of course there is a bit of poo and right to buy around the other side might to sticky tape of that area just sampled person I think this can be any great surprises are my concern is don't have is that if it's the food and that's relatively easy arm if it's not then we have to satisfy well what is the reason it keeps happening about grab hold of that it will cost about Muncie mums car predominantly that may be not by the Muncie mums car but I would be debt loss without and so the right ear obvious equivalent mess the left one not so bad can we look at the belly to stand up and back legs and we have just hairy and heavy okay down the floorhave a treat after all that Gracie can ever treat so right give you a minute and if you give me a minute and get myself sorted out showed down the microscope but I to get it fixed on for your bow first have to do the staining and we would prefer you do not own home with unexpected stains like Andrew does all the time hi cashINVESTIGATIONS:if you look at the screen what I say will so I'm not interested me your much more interesting Gracie I thought I was entertaining say look see their turnaround see that little spotsee when I say things it appears on the screen can you read that that's very small over there.Now I'm gonna look down the microscope and see what we see it does and I was get it right sometimes it says things I don't say CSO is check so cytology from the left ear canal showed moderate numbers of squames okay and the right ear canal to the infected one shows you could go Alysia LeWitt long weekend to get rid of the stained fingers for you to go back to school ISOs for Friday the worked a school days and I don't work tomorrow is my brain is already already well as I do my other stuff cytology from the right ear canal showed nuclear strands budding yeast and frequent cocciPROCEDURES:ASSESSMENT: Bonnie's clinical signs and history are most consistent with chronic Bacterial Folliculitis that has relapsed. The screening blood tests rule out hypothyroidism. The slight elevation of ALP is relatively non specific as other liver enzymes are normal and there is no stress leukogram that would be expected with hyperadrenocorticism. There is now Malassezia Otitis Externa affecting the Right ear and persistent allergic otitis of the left ear. A specific cause of the recurrent pyoderma was not identified. The relapse after 6 months suggests either a seasonal factor or intermittent allergen exposure as the trigger. The IgE assay was positive only for mould mites and does not correlate with the relapsing pyoderma. DIFFERENTIAL DIAGNOSES: Atopic dermatitis – confirmed. Cutaneous adverse food reaction – confirmed. Bacterial folliculitis – confirmed/ controlled. PROGNOSIS: Bacterial pyoderma usually develops secondarily to either allergic skin disease, parasites or systemic illnesses that have suppressed the normal immune response. In most cases the bacterial pyoderma responds to appropriate treatment within five to seven days but often treatment needs to be continued for many weeks to get complete resolution. If the underlying reason for the bacterial pyoderma is not identified and corrected the infection is likely to recur. In some cases, regular use of antibacterial shampoos ± lotions may reduce frequency of recurrence. We are seeing increased patients with antibiotic resistance so if there is a perceived failure to respond to treatment bacterial cultures may need to be performed. Atopic dermatitis cannot be cured. In most cases the severity of the signs markedly decreases, once the secondary infections (usually Malassezia or Staphylococcus intermedius) and any aggravating factors (food hypersensitivity, contact allergic dermatitis or flea hypersensitivity) are controlled. The remaining pruritus can usually be controlled with a range of treatments. Unfortunately, each of the treatment options have advantages and disadvantages. Therefore, treatment must be tailored to the individual animals and their owners’ needs. Food hypersensitivity cannot be cured but can usually be managed by restricting access to specific food components. In most cases, foods incriminated are high in protein, including meats, egg, cereals, milk, and soy. In some cases very small amounts of food may trigger the allergic response even if infrequently fed. In others small amounts of exposure may be tolerated without causing significant problems. Occasionally animals will develop new food hypersensitivities. PLAN:The following recommendations and treatments were made for Bronny:Restart the strict diet based on Royal Canin Anallergenic withn the SPD turkey or duck.Medications Dispensed:30.00 x Apoquel 16mg tab (Oclacitinib) Rx: Give 1/2 ( HALF) tablet TWICE daily for up to 14 days then reduce to 1/2 (HALF) tablet ONCE daily ongoing. With or without food. Mometamax Ultra Ear Treatment 0.8ml/dose (POSACONAZOLE)(16) Rx: Instil 0.8ml into the Left ear once.  Cortavance Spray 31ml (Hydrocortisone) Rx; Instil 1 ml into the Left ear weekly.Pyohex shampoo Rx: Apply a rich lather all over twice weekly leaving on skin for 10 minutes before rinsing well. Towel dry then apply the Pyohex conditioner to the lesional areas.If there is not good response to the Pyohex shampoo within the first two weeks contact Dr Carter who will arrange to dispense an additional course of clindamycin.Other Medications:FOLLOW UP:Anne- Marie was asked to report on Bronny's progress if ther is nort good progress in 2 weeks.REVISIT:We will reexamine Bronny in about 3 weeks time.    Vital Signs