C10008651 / invoice 10000

Reason: LM Rehceck And Discuss SkinAppointment Notes: LSHistory:  Diet:EXAMINATION: HistoryPresenting Complaint:Walther presents for post-surgical follow-up and evaluation of skin conditionPatient History:- Recent nasal surgery with sutures placed- Developed widespread skin lesions and pruritus following surgery - has never had skin issue previously - Client bathed patient 2 days post-surgery- Concurrent ear problems with malodour and discharge- No environmental changes (same grass, food, no new plants)- New puppy acquired at Christmas - normal play behaviour between dogs- No previous history of skin or ear problems- Currently using Malaseb shampooExamVital Signs:Weight: 50.0Temperature: *NAD*Heart Rate: 110Respiratory Rate: pantMucous Membranes: pink and moistBCS: 5/9Findings:Eyes: NADEars: *AU erythematous, warm, malodorous yellowy-brown crusty discharge*Nose: *Surgical site healing well, sutures intact*Oral: NAD - mm pm <2Heart: Normal rate and rhythm, no murmursPulses: Strong and synchronousLungs: NAD bilaterally all fieldsMusculoskeletal: No appreciable lameness, normal muscle mass/toneIntegument: *Widespread erythema, scaling, pustular lesions on body and limbs*Peripheral Lymph Nodes: WNLAbdomen: Soft, non-tender, no masses or organomegaly appreciableExternal Urogenital: NADRectal Exam: Not performedNeurologic: Full neuro exam not performed. Neurologic status appears WNLAssessmentProblem List:- Allergic dermatitis - r/o environmental allergens, food sensitivity, contact dermatitis- Otitis externa - r/o secondary bacterial/yeast infection, allergic inflammation- Histiocytoma (historical finding) - r/o benign round cell tumourDiff dx::- Histopathology results: Round cell tumour favouring histiocytoma (benign, self-resolving)CommunicationCommunication:- Discussed allergic skin disease pathophysiology and secondary bacterial overgrowth- Explained ear anatomy and predisposition to infection with compromised skin barrier- Discussed treatment options including cortisone vs immunomodulators (Apoquel, Cytopoint)- Advised on diluted Malaseb for ear cleaning- Explained histiocytoma results - benign, self-resolving tumour- Client agreed to prescribed treatment plan- Recheck appointment scheduled in 10 daysTreatmentTreatment Plan/Medications:- Rx: Cortisone (dose and duration to be confirmed)- Rx: Ear medication - 2 drops AU twice daily initially, then once daily- Continue Malaseb shampoo as currently usingPlan- Recheck in 10 days to assess response to treatment- Monitor ear condition and may need further cleaning if required- Sutures will fall out naturally- Continue current management and monitor for improvementTREATMENT:  Macrolone tabsPMP for earsPLAN:10 days for RV    Vital Signs    Weight: 50;       MMColour: pink;       HeartRate: 110;       BodyScore: 5/9;       DentalGrade: 0;       CRT: < 2 secs;