C10001274 / invoice 10000

Allergies - eyes itchy and red
Vetstoria Appointment

Consult - General
PRESENTING COMPLAINT:  
(Was on Pred EOD since Dec - course finished 4 weeks ago, symptoms returned as soon as Pred stopped.
No response to high dose Cytopoint
Os have trialled elimination diets previously 
Symptoms improved over Winter and worse in warmer months.
Single vomit the other day after dinner, nil otherwise)

SUBJECTIVE/ HISTORY:
EDUF normal - always a picky eater. Always drinks well. 
  Current Medications: (Zyrtec)
  Vaccination Status:  (UTD)

OBJECTIVE/ EXAMINATION:
Temperature:(normal peripherally, rect temp not performed)
Mentation (BAR) BCS:(6)/9
Hydration:(Normal)
Mm pink and moist, CRT <2 sec
Dental:(No calculus or gingivitis)
Oral exam: (NAD)
Eyes: (Periorbital dermatitis bilaterally secondary to pruritis)
Ears: (External ear canal bilaterally erythemic + mod dark brown ceruminous discharge )
HR: (136) bpm, rhythm (reg), Mumur (nil), pulses (synchrnous)
RR: (panting) pm, effort (nil), Aus pulmonary fields (clear)
Abdominal palpation: (Comfortable on palp, tense due to anxiety)
Integ: skin and coat healthy, no obvious lesions or lumps noted, normal skin recoil
Msk: (Normal ambulation, NAD)
Peripheral LNs: (WNL)
Neurological: a full neurological exam not performed

LABORATORY:
(IH cytology for ears
Cocci++ and Malassezia +++ bilaterally)

ASSESSMENT/ PROBLEM LIST:
(Pruritis ears, ventral abdo )

DD's:
(Atopic dermatitis)

TREATMENT:
(Home with Apoquel 10.8mg PO BID for 2 weeks then reduce to 10.8mg PO SID on going.
+PMP 0.5ml bilaterally for 10 days - first dose given in consult with O's)

PLAN:
(Recheck ears in 10-14 days. Sooner INI)

OWNER COMMUNICATION NOTES:
(Discussed 6monthly bloods to monitor whilst on Apoquel.
Rec trying to have a consult with Dr Neal Loh at Holistic Pet Vet for TCVM approach in addition to current treatment plan as will need to manage allergies lifelong and may be able to support the immune system through herbs.)