C10008730 / invoice 10000

## Signalment- Name: Mac- Species: Dog (breed not explicitly stated; owner mentions breed predisposition to skin issues)- Sex/Neuter status: Male, desexed- Age: ~1.5 years- Weight: 21 kg- Microchipped: Yes## History- Diet history:  - Puppy food (beef-based) until ~1 year old without issues.  - Switched to adult food around 5 months ago; tried chicken briefly, then reverted to beef/lamb adult food.  - Owner has been adding an oil supplement to diet.- Parasite prevention: Monthly oral product reported as NexGard Spectra (blue/blue-white box).- Bathing: Sensitive wash; not too frequent.- Medications/conditions/surgeries: None reported. No chronic health issues noted.- Lifestyle: Not detailed; indoor/outdoor not specified.## Subjective- Presenting complaint: Pruritic skin lesions with crusty, multiple spots on back, focal alopecia; very itchy and restless when petted, especially at night.- Additional concern: Red/pink paws with licking (pododermatitis-like signs).- Duration: “A few months,” roughly coinciding with diet change and summer season.- Owner questions:  - Whether signs could be food-related vs seasonal atopy.  - Whether to revert to puppy food.  - Interest in costs/efficacy of anti-itch injection vs diet trial.- Preferences: Leaning toward trying strict diet (hydrolyzed protein) first; open to injection option if needed.## Objective- Physical exam (general):  - Cardioresp: NAD; no audible murmurs, wheezes, or crackles.  - MM: Pink  - CRT: 1–2 sec  - TPR: WNL  - Abdomen: Soft; no gas/free fluid or organomegaly  - Eyes: NAD; no discharge; symmetrical  - Ears: NAD; moderate hair/cerumen; no otitis noted  - Oral/Dental: NAD  - Lymph nodes: NAD  - Musculoskeletal: NAD  - Neurological: NAD  - Behavior: Docile and friendly- Dermatologic findings:  - Multiple crusted papules/plaques on back with focal alopecia.  - Paws pink/red; history of licking (four paws affected).  - Pruritus present; patient rubs against objects.- In-clinic testing:  - Skin cytology from lesions: – no significant bacteria or yeast observed.- Procedures:  - Skin sampling noted minor bleeding; resolved.## Assessment- Pruritic, crusted dermatosis with focal alopecia and paw erythema in a young, desexed male dog.- No secondary bacterial or Malassezia overgrowth detected on cytology today.- On consistent monthly isoxazoline preventive (NexGard Spectra), reducing likelihood of flea/lice/mites.- Onset overlaps with dietary changes (introduction of chicken, then beef/lamb adult food) and summer (high environmental allergens).- Most consistent with allergic dermatitis: atopic dermatitis (environmental/seasonal) and/or cutaneous adverse food reaction (food allergy).## Differential Diagnosis- Atopic dermatitis (environmental/seasonal allergy to pollens/mites)- Cutaneous adverse food reaction (most commonly to chicken or beef proteins)- Less likely given prevention and cytology: ectoparasites (fleas/cheyletiella/sarcoptes, demodex not assessed today), secondary bacterial pyoderma, Malassezia dermatitis- Other less likely: contact dermatitis, dermatophytosis (ringworm), folliculitis of other etiologies, autoimmune dermatoses## Diagnostics/Laboratory- Performed today:  - Skin cytology: No significant bacteria/yeast seen.- Recommended/organized:  - Strict 8-week elimination diet trial with hydrolyzed protein diet (Hill’s Prescription Diet z/d).  - Consider skin scrapings and/or trichogram if lesions persist or worsen to definitively rule out mites/demodicosis.  - Consider fungal culture/PCR if lesions are atypical or unresponsive.  - If pruritus persists after elimination diet: intradermal or serum allergy testing to guide ASIT; or therapeutic trials (oclacitinib/ lokivetmab) to support atopy diagnosis.  - Baseline dermatology photos today (owner to take) to monitor response.## Tentative Diagnosis- Allergic dermatitis with top differentials:  - 1) Cutaneous adverse food reaction  - 2) Atopic dermatitis (seasonal/environmental)## Tentative Prognosis- Short-term: Fair to good with appropriate management; pruritus may decrease within weeks on correct therapy.- Long-term: Good control achievable; may require ongoing dietary management and/or anti-pruritic therapy and topical care. Relapses possible with allergen exposure or dietary lapses.## Plan- Discussed two primary pathways:  1) Anti-itch injection (cytopoint )plus antiseptic shampoo for 4–6 weeks to assess response (addresses atopy but confounds food trial).  2) Strict hydrolyzed protein elimination diet for 8 weeks without anti-itch meds to assess food allergy (preferred today).- Selected plan today: Elimination diet trial.  - Diet: Hill’s Prescription Diet z/d (hydrolyzed protein).  - Transition:    - 03/10/2026–03/23/2026: Mix 50% current food + 50% z/d each meal.    - 03/24/2026–05/05/2026: 100% z/d only.  - Absolute restrictions during trial:    - No treats, table scraps, oils/supplements, flavored medications, or chewable preventives with flavorings; water only plus z/d.    - If parasite prevention is flavored, discuss non-flavored alternative during trial.  - Monitoring:    - Expect gradual reduction in itch/redness and crusting; hair regrowth follows as inflammation resolves.    - Do not judge outcome until completing full 8 weeks.  - After trial:    - If improved: transition to a novel single-protein maintenance diet with a protein he has never had (e.g., kangaroo, goat, duck, turkey, lamb if truly novel) and avoid chicken/beef.    - If no improvement: pivot to atopy management (anti-itch injection or other therapies) and consider allergy testing.- Topicals:  - May use antiseptic shampoo as needed if advised, but avoid adding confounding therapies during the strict trial unless infection develops.- Today’s treatments: No medications administered in-clinic; skin cytology performed.- Client education:  - Read bag feeding guide for 21 kg dog; adjust amounts per brand calorie density.  - Start with smallest bag to ensure acceptance before purchasing larger size.## Follow up- Recheck appointment: Around 05/05/2026 to evaluate 8-week trial outcome.- Interim check-in: Contact clinic if worsening occurs; optional photo updates at 2 and 4 weeks.- If improved at 8 weeks: Plan and implement novel protein maintenance diet; schedule follow-up 2–4 weeks after switch.- If not improved: Discuss anti-pruritic options (e.g., injection lasting ~4–6 weeks), further diagnostics, and long-term atopy plan.## Declined services/steps/options- Anti-itch injection option discussed but deferred in favor of a definitive elimination diet trial.- No additional diagnostics (scrapings/cultures) performed today beyond cytology.## Warnings- Any flavored medications, treats, oils/supplements, or table scraps during the elimination trial can invalidate results.- If pruritus escalates, new lesions spread, pustules develop, or signs of infection (odor, exudate) appear, contact the clinic promptly; secondary infections may need antibiotics/antifungals.- If gastrointestinal upset occurs with diet change (vomiting/diarrhea, inappetence), notify the clinic to adjust transition pace or consider alternative hydrolyzed diet.- If a dose of parasite prevention is due during the trial, ensure it is non-flavored or discuss timing/alternatives to avoid confounding the trial.    Vital Signs    Weight: 21;