C10006286 / invoice 10000

licking one of her paws continuously for a few days very red, irritated
very red, irritate
Location of lesions 
Hair lossleft forelimb- all reddenned and 
Itching/ scratching/ rolling / pawing / 
Diet  chicken 
Malaseb none 
Dewormed  NGS
Visible fleas none
Skin -Sticky tape exam 
cocci in pairs - large 
ketarinocytes  +++
Squamous cells +++
Neutrophils none

DD Allergic / contact dermatitis/ 
Discussed single protein diets and dietary trials to identify source of allergy 
TREATMENT
Tab Amoxyclav 
1 BID x 10 days
Shampoo  malaseb x 10 min contact time apply mixed with water repeat every 4 days
Tab Macrolone 20 mg x 15   1 BID x3 days   sid x 5 days    Then 1/2 on alternate days  until course completed 
report back after 15 days for a recheck

PLAN
If no improvement, will try CYTOPOINT

c7 yearly vac

HISTORY
Has had C2i before - wants C2I today too discussed lepto 2 vaccine
EDDU normally, no other health concerns
Parasite prevnetion: on credelio monthly

PHYSICAL EXAM
BAR
BCS 4.5/9
Eyes NAD
Nose NAD
Ears NAD
Mouth NAD
Gums pink and moist
CRT <2s
Teeth Dental Disease Grade 1/4- staining on canines 
Coat salive staining on both fron paws
Integument NAD 
Lymph Nodes (submandibular and popliteal): normal size and consistency
HR 92bpm, no heart murmurs or arrythmias auscultated
Chest NAD, no crackles or wheezes auscultated 
Abdomen soft and comfortable on palpation, no masses or organomegally palpated 
Temp 38.5
Femoral Pulse strong and synchronous to HR

ASSESSMENT
Fit for vaccination 

PLAN
Protech bonchi-shield oral vaccine BATCH 5245044A    EXP 16.07.2026
Protech C4 BATCH 5257035B   EXP 07.08.2026 given SC 
Protech C2i BATCH 3291023    EXP 29.05.2026 given SC 
Back in 1 year for next booster vaccination

DISCUSSION
Flea/tick/worm prevention
Anxiety separation
Oral hygiene

c7 vaccination

Presented for:  Annual Vaccination.
Outdoor/ Indoor mostly
Diet: fresh chicken kibble , wet food 
Activity: - adequate
Vaccination status
EDDU - normal 
Deworming / Tick/ Flea control  UTD - was on Nexguard now changed to another which Nala prefers .
Vomiting / Diarrhoea/ Coughing / Allergies None 
Mentation: BAR 
Temperament: Friendly
Body condition Score:4 /9 
Mouth: Mucous membranes pink and moist. 
Capillary refill time in seconds: 2
Hydration status: adequate
Oral cavity - NAD
Teeth: 1/4 staining on all canines and incisors, mild gingivitis? the base of all canines are reddish
Eyes: NAD
Ears: No inflammation of external ear canals, Mild amount of gunk- Clean regularly 
Lymph nodes: Peripheral lymph nodes normal size, shape, and consistency. 
Cardiovascular: Cardiac auscultation revealed no systolic murmur. No gallop rhythm. Good pulse pressure, synchronous to HR. No arrhythmia.
Abdominal palpation: Soft and comfortable. No masses or organomegaly detected. 
Respiratory: The lungs sound normal. Normal respiration rate and effort. 
RR: 28  /min 
Musculo-skeletal: Ambulatory. No lameness noted. 
Neurological: Normal mentation. Normal gait. 
Integument: Good haircoat. Normal skin turgor. 
External genitalia: NAD

*Assessment
Fit for vaccination.

*Treatment
Inj ProTech C4 + Inj Protech CI2 - SC   
BB oral 

nails clipped 
 Advised dental care, keep a regular watch, brush daily if possible, or clean with a wet towel
Administer either oravet dental chews or similar preparations

Next vaccine due after a year