C10006720 / invoice 10000

Reason: Irritation Under NosePrimary Presenting Complaint:Lesion under nose (lateral aspect of right nasal opening)Other Complaint:Scooting behavior notedHistory:    - Last Normal - Lesion first noticed previous night    - Frequency -     - Last Ate -     - Vomiting -     - Stool -     - Urination -     - Drinking -     - Medicine Hx -     - Diet -     - Vacc Current -     - Worming Hx -     - Heartworm -     - Microchip - Y/N - scanned - ok?Examination:Presenting with acute nasal lesion requiring anti-inflammatory and antimicrobial therapy    - Attitude - BAR, not bothered by lesion    - Body Score - /10    - Hydration status -     - Temperature -     - Heart - HR. Murmur -    - RR -     - Dental - Score(0-4)=     - CRT - immediate    - Eyes - NVL    - Ears - clean and discharge free    - Abd Palpation - Unremarkable    - Gastrointestinal - No Sig Findings    - Urogenital - No Sig Findings    - Skin - 1x1cm ovoid pink inflamed tissue on lateral aspect of right nasal opening, appears red, inflamed, almost ulcerative. Dermatosis present on dorsal aspect of nose.    - Musculoskeletal - No Sig Findings    - Neurological - No Sig Findings    - Lymphatic - No Sig Findings    - Other Key Findings - Assessment:Likely traumatic lesion or bacterial/fungal folliculitis of the nasal area. The inflamed, ulcerative appearance and location necessitate systemic rather than topical therapy due to inevitable licking behavior.Problem List:- Acute inflamed lesion lateral aspect right nasal opening (1x1cm, ovoid, pink, red, almost ulcerative)- Dermatosis on dorsal aspect of nose- Scooting behaviorDDx:DDx for nasal lesion:- Traumatic dermatitis- Bacterial folliculitis- Fungal infection (dermatophytosis)- Contact dermatitisDiscussed:Owner consented to systemic treatment approach. Discussed that topical therapy would be ineffective due to location and licking behavior. Explained potential corticosteroid side effects including lethargy, increased appetite, polydipsia, polyuria, and rare vomiting. Owner instructed to discontinue medication if vomiting occurs. Owner agreed to treatment plan and associated costs.Treatment Plan:- Dexamethasone 2ml SC administered- Cephalexin 600mg PO BID for 14 days- Prednisolone PO at reducing dose for 2 weeks- Daily cleaning of lesion with dilute betadine solution- Monitor for improvement and steroid side effectsOngoing Prescriptions:Next Visit:Return to clinic if condition worsens or fails to improve with current treatmentThe above clinical notes were created with the assistance of Astro Scribe under the supervision of the consulting Vet.    Vital Signs