C09999145 / invoice 10000

Weight (Kg):8.20
History:HISTORY:
Presents for a flare-up of pododermatitis, primarily affecting the right hind paw. O reports Millie has been licking the paw excessively since they returned from being away. O has tried Malaseb shampoo and Neocort cream at home with minimal improvement. Hx of atopy, sensitive stomach, and vomiting with oral medications. Last Cytopoint injection was ~4 weeks ago.
EDDU normal. No v/d/c/s. Normal energy levels.
Current medication: an unknown human antihistamine.
Parasite control: UTD nexgard spectra

EXAMINATION:
BAR, anxious
Cardio: no murmurs or arrythmias auscultated, both pulses strong and synchronous
Resp: panting
MMS: pink moist CRT 1.5s
Integument:
- Right hind paw is saliva stained with a small area of self-trauma (erythema, minor bleeding). Other paws are mildly affected.
- Occasional cocci on in house cytol

ASSESSMENT:
- Atopic dermatitis flare-up with secondary pododermatitis.
- Mild superficial bacterial overgrowth confirmed on cytology.

PLAN:
- Cytology (tape prep) from RH paw performed in-house: revealed mild bacterial overgrowth.
- Dispensed Cortavance spray. O instructed to apply one spray to the affected paw once daily for 7 days.
- O to monitor for improvement and call on Saturday if licking persists. At that time, oral medication (Apoquel) may be discussed as an alternative.

COMMUNICATION:
Discussed likely causes of pruritus in dogs (FAD, atopy, food allergy). Explained the plan to use topical therapy to avoid oral medications due to Millie's history of vomiting. O happy with above plan.

EC