C09995480 / invoice 10000

shaking head + wound on R flank + hair loss left flank
being brought in by Tracey Rath


GapOnly
Pet Primary Diagnosis/Suspected Diagnosis:(otitis externa, pruritus )
Suspected Cause:(malasezzia )
Any other conditions being treated, if any:(none)
Known health concerns:(none)
Date of first clinical signs, if known:(28/2/26)





Hx:  1st visit to MV? (Y/N)
Demeanour ( BAR QAR anx )
Current diet ( )
Parasite crtl UTD?  ( ) 
EDUF habits - 
Any V+/D+ ?  (Y/N)
urine : (normal/abnormal)     faeces: (normal/abnormal)
?sig health issues to chk (Y/N) if Y - detail  of problem - 

PE:
Teeth/oralexam: 
Eyes: NAD
Ears: NAD
Nose: NAD
Heart sds: NAD
Lung sds: NAD
LN: NAD
Skin/Coat: NAD VGC
Abdo: NAD
Limbs/feet: NAD


Problem List:
1) 
2)
3)

Discussion/TMT Plan:



Cost concerns?  (Y / N)  if Y detail - None Mentioned

RX:

Verified: NO

HISTORY
Presenting for: Oreo, a 10-year-old male entire dog presented for skin issues around a healing wound and ear problems with head shaking.
Historical Conditions: Previous skin issues noted
Skin: Healing wound from apparent dog bite that occurred a couple of weeks ago, constant scratching at the area, redness around wound site from scratching, had been applying Neocort cream but ran out, wearing collar but still able to scratch with feet
Current Meds: Neocort cream - discontinued (ran out), Epiotic ear cleaner used but head shaking persists
Other: Dog sitting arrangement until Tuesday

EXAM
Mentation: BAR
Behavioural: Cooperative during examination, allowed handling and examination procedures
Eyes: No abnormalities noted
Ears: Bilateral pruritus, not terribly dirty but definitely very pruritic, erythema noted, bilateral ear involvement
Integumentary: Healing wound site with evidence of scratching trauma, redness around affected area from self-trauma, chronic inflammation noted in paw webbing bilaterally with erythema, evidence of paw licking
Urogenital: Intact male, testicles present
Diagnostics: Bilateral ear swabs collected for cytological examination

ASSESSMENT
Healing dog bite wound with secondary self-trauma - wound appears to be healing appropriately but ongoing pruritus causing continued scratching and irritation
Bilateral otitis externa - pruritic ears requiring cytological evaluation and treatment
Chronic pododermatitis - chronic inflammation in paw webbing suggestive of possible allergic dermatitis
Intact male status - discussion regarding desexing for health benefits given age (10 years) to reduce risk of testicular and prostate cancers

PLAN
New Meds/Tx:
- Cytopoint injection administered for allergic dermatitis and pruritus management
- Oral antibiotic prescribed for potential secondary bacterial infection in bite wound (dog bite wounds can introduce bacteria and debris under skin)
- Neocort cream dispensed for continued topical treatment of healing wound
- Ear treatment prescribed for one week duration for bilateral otitis externa

Additional Discussion:
- Recommend physical barrier such as child's t-shirt to prevent scratching while allowing breathability, as collar ineffective against hind feet
- Discussed desexing benefits for 10-year-old intact male including elimination of testicular cancer risk and reduction of prostate problems
- Advised treatment continuation until dog returned to owner on Tuesday
- Recommended recheck in one week when dog returned to owner for evaluation of ear treatment response

vacc

GapOnly
Pet Primary Diagnosis/Suspected Diagnosis:(allergic dermatitis)
Suspected Cause:(env allergens)
Any other conditions being treated, if any:(none)
Known health concerns:(none)
Date of first clinical signs, if known:(- )

HISTORY
Presenting for: Oreo presented for annual health check and vaccination
Historical Conditions:
- Previous ear/bum itching issues
- Foot licking/dermatitis
- Dental cleaning and lump removal in 2023
Diet: Normal
Skin: 
- Chronic foot licking with associated redness
- Perianal redness noted frm XS licking 
Current Meds:
- Topical cream for feet (inconsistent use)
- Monthly parasite prevention up to date

EXAM
Mentation: BAR
Wt: 9.9 kg (increased from 9.4 kg previously)
T: 38.3¡C
Behavioural: Friendly, cooperative but resents oral exam - flicks head around
Ears: 
- 2mm pigmented  skin tag on left ear, inner pinna
- No evidence of infection or inflammation
Integumentary:
- 3-4mm pink skin tag in left axilla, unchanged from previous exam
- Erythema of feet and perianal region
- Evidence of chronic paw licking
Abdomen - NAD, entire male both testes desc and same size 
MSK - inflammed feet webbign but OW NAD

ASSESSMENT
Pedal and perianal dermatitis - Likely allergic in nature given chronic presentation
Benign skin tags (left ear and left axilla) - Stable, monitoring recommended
Mild weight gain - Otherwise apparently healthy

PLAN
Vaccinations:
- Annual vaccination administered Pi2 adn BSO with difficulty!

New Meds/Tx:
- Recommended oral medication trial for dermatitis/pruritus - Apoquel 5.4mg BID 7d then SID 
- Discussed potential GI side effects (vomiting/diarrhoea) but noted >95% of dogs tolerate well
- if going well and O would like more can either dispense or do a prescription for this (o can decide) 

Client Comms:
- Monitor skin tags - return if bleeding or increasing in size
- Recheck exam recommended at 12-13 years of age, then transition to 6-monthly exams
- Discussed age-related health considerations including potential prostate issues and testicular cancers which recc neutering if start to be an issue.

KC and anal glands



Hx:  1st visit to MV? (Y/N)
Demeanour ( BAR  )
Current diet ( can food, dry food, chicken brest)
Parasite crtl UTD?  ( UTD ) 
EDUF habits - all wnl 
Any V+/D+ ?  (N)
urine : (normal)     faeces: (normal)
?sig health issues to chk (Y/N) if Y - detail  of problem -  on-going skin issue, but managed by neocort and malaseb shampoo

PE:
Teeth/oralexam: grade 2/5, VGC, done dental recently
Eyes: NAD
Ears: NAD
Nose: NAD
Heart sds: NAD
Lung sds: NAD
LN: NAD
Skin/Coat: ventral side of the base of the tail has saliva stain. the dorsal part of anus is swelling and red
Abdo: NAD
Limbs/feet: saliva stain of all the foot. 

expressed the anal glands: secretion is liquid
rectal exam: prostate about 2cm size? 

Problem List
1) pruritus 


Discussion/TMT Plan:
- suggest O can have cytopoint injection to help with the itchiness if neocort and malaseb is not enough. 
- fit for vac


Cost concerns?  (N)  if Y detail - 

RX: C4 SC between shoulder, Bb given orally