C10009387 / invoice 10000

scratching alot mh

Verified: NO

HISTORY
Presenting for: Beau Carter, a 9-month-old male dog presented for generalised pruritus with small red lumps on the belly, groin area, under the neck and arms, with scratching behaviour.
Skin: Owner reports generalised itching with small palpable lumps that are not immediately visible and not red underneath. Pruritus mainly affecting groin area, under neck, and under arms. Abdomen showing early signs but owner concerned it will worsen if left untreated.
Other: Currently working with a dog trainer due to nervous temperament. Food driven which assists with training and desensitisation.

EXAM
Wt: 38 kg
Behavioural: Initially nervous and anxious when first meeting veterinary staff, but settles quickly once familiar. Readily accepts treats during examination indicating comfort level. Food motivated which aids in positive reinforcement during handling.
Integumentary: Generalised mild erythema noted. Small red lumps resembling pimples observed on ventral abdomen appearing as small dots. Mild erythema present between paws. Generalised pruritic behaviour observed with patient scratching multiple areas including head.

ASSESSMENT
Allergic dermatitis with secondary bacterial pyoderma - Likely heat and humidity exacerbated allergic skin condition with secondary superficial bacterial infection presenting as pimple-like lesions. Breed predisposition noted, particularly in pale/white dogs.

PLAN
New Meds/Tx:
- Medicated shampoo for secondary bacterial infection. Wet body excluding head and ears, lather on affected areas (belly, ventrum and rest of body), leave for 10 minutes contact time, then rinse thoroughly
- Prednisolone 20mg once daily for 5 days, then 10mg (half tablet) once daily until finished to reduce pruritus and inflammation
- Cortisone cream with numbing component and antibiotic available if needed for hairless areas, but starting with tablets and shampoo initially

Additional Discussion:
- Discussed pruritic cycle and importance of breaking the itch-scratch cycle before skin breakdown occurs
- Heat and humidity contributing to current flare-up
- Positive socialisation visits to clinic recommended with treats to reduce anxiety and create positive associations

final booster sm

Hx: owner health concerns: ()None
eating, drinking, urinating, defaecating normally

Current medications: ()

intestinal worming :() up to date
heartworm:() up to date
flea control :() up to date
tick control  :()up to date
VACCINATION STATUS : (final C5 vacc today)

Subjective:

Demeanour:BAR ()
Condition:WNL()
Ambulation:WNL()
Pain scale 1-5()
Hydration status (%):WNL

Objective:

Vitals: mm pink, crt 1 sec, moist
 RR:()   Respiratory Character: (normal effort)  PR: () Pulse character: (normal) Temp ()
Oral: Gums and teeth (WNL), Pharynx (WNL)
aural: nad()
ocular : nad()
thoracic auscultation : no murmurs, no arrythmias, normal breath sounds ()
abdomen: nad on palpation ()
skin and coat : nad ()
musculoskeletal : ambulatory without lameness ()
lymph nodes : nad()
Rectal Exam: Not performed()
Urogenital system(wnl)
CNS : Mentation(BAR) Cranial Nereve Exam (WNL), Concious Propioception and reflexes (WNL)

Problem list ()

Differentials()

Diagnostics results/discussion/assesment()

Treatment(C5 injectable)

Plan (Booster vacc in 12months. Continue with puppy school and dog training. Talked about delaying desexing until fully grown for MSK reasons...both Beau and Artemis live together so are a mating risk...O may opt to desex Artemis earlier depending on how first season goes , but ideally will delay)

Prognosis()

 

2nd pup vacc. dc
o aware last one must be done at 16 weeks

Hx: owner health concerns: ()None
eating, drinking, urinating, defaecating normally

Current medications: ()

intestinal worming :() up to date
heartworm:() up to date
flea control :() up to date
tick control  :()up to date
VACCINATION STATUS : ()

Subjective:

Demeanour:BAR ()
Condition:WNL()
Ambulation:WNL()
Pain scale 1-5()
Hydration status (%):WNL

Objective:

Vitals: mm pink, crt 1 sec, moist
 RR:()   Respiratory Character: (normal effort)  PR: () Pulse character: (normal) Temp ()
Oral: Gums and teeth (WNL), Pharynx (WNL)
aural: nad()
ocular : nad()
thoracic auscultation : no murmurs, no arrythmias, normal breath sounds ()
abdomen: nad on palpation ()
skin and coat : nad ()
musculoskeletal : ambulatory without lameness ()
lymph nodes : nad()
Rectal Exam: Not performed()
Urogenital system(wnl)
CNS : Mentation(BAR) Cranial Nereve Exam (WNL), Concious Propioception and reflexes (WNL)

Problem list ()

Differentials()

Diagnostics results/discussion/assesment()

Treatment()

Plan ()

Prognosis()