C10005742 / invoice 10000

SubjectivePresenting Concerns:  Bruce was presented for a consultation regarding his deferred aggression. The owner reports that after an aggressive interaction with the neighbor's dog through the fence, Bruce will redirect his aggression onto one of the other dogs in the household. The owner feels this behavior has become slightly worse since he started treatment for his thyroid condition.    Historical Conditions:-   Previously treated with fluoxetine approximately 2.5 years ago.  Current Medications:-   Receiving medication for a thyroid condition.-   The owner has been administering a supplement containing L-theanine.  Lifestyle Risk Factors:-   Lives in a multi-dog household.-   Engages in fence-fighting with a neighboring dog.ObjectiveMentation: BAR  Wt: —  BCS: --/9  T: Not taken  P: —  R: —  MM: pink/moist. CRT < 2sec.  Hydration: Normal    Emotional Assessment: Anxious. The owner reports that Bruce does not socialize well and needs to be moved through the clinic carefully to avoid stressful interactions.    Eyes: Clear. No discharge or erythema OU.  Ears: Clean with no discharge or erythema AU.  Nose: Clear, moist without discharge.  Throat: No inducible cough upon tracheal palpation; no palpable masses.  Oral: Calculus and gingivitis absent. No masses or other lesions.  Cardiovascular: No murmurs or arrhythmias, strong synchronous pulses.  Respiratory: Normal bronchovesicular sounds bilaterally.  Abdominal: No organomegaly or mass effects. No pain on palpation.  Lymph Nodes: No peripheral lymphadenopathy.  Integumentary: No evidence of ectoparasites, full coat with clear skin.  Neurologic: No ataxia, normal mentation.  Musculoskeletal: Ambulation normal, no lameness observed.  Urogenital: Normal external anatomy.  Rectal: Not performed.AssessmentDeferred Aggression – Behavioral issue characterized by redirection of aggression towards housemates. This is triggered by high arousal from interactions with a neighboring dog through a fence. The behavior may be exacerbated by increased confidence or energy levels secondary to treatment for hypothyroidism.    Otherwise apparently healthy – The patient is physically well based on general observation.PlanMedications/Treatments:-   A Rx for fluoxetine was provided.-   Instructions are to start with one 20 mg capsule PO SID. This dose can be increased to two capsules (40 mg) daily if needed.-   The Rx is for 2 boxes and is valid for 6 months.  Additional Discussion:-   The owner inquired about using L-theanine concurrently with fluoxetine. The potential risk of serotonin syndrome was discussed. It was concluded that the risk with this combination is likely low. The recommended dose for a dog over 25 kg is 100 mg BID for long-term use.-   It was confirmed that there is no significant drug interaction between fluoxetine and thyroid hormone medication. An interaction is more common with tricyclic antidepressants, which are a different class of drug.-   A preliminary discussion was held about the client potentially running puppy school classes at the clinic. Logistics regarding timing, space, and compensation were briefly discussed.    Vital Signs