C10010340 / invoice 10000

recheck skin with MG
still itchy around her tummy 
cortadvance
Subjective
Presenting Concerns:  
Lucy presented for re-evaluation of pruritus. The owner reports that the itching has worsened despite treatment with Xenorelial and has now spread from her mouth to her abdomen and feet.  
  
History Updates:
-   The owner reports that the previously prescribed Xenorelial tablets have not been effective in controlling the pruritus.
-   The itching is now described as generalized, affecting her chin, abdomen, and feet.
-   The patient is walking well and is otherwise well at home.
-   No other medications are currently being administered.

Objective
Mentation: BAR  
MM: pink/moist. CRT < 2sec.  
Hydration: Normal  
  
Emotional Assessment: The patient was noted to be stressed during the examination and would not accept treats. She appeared more comfortable while on the owner's lap.  
  
Physical exam limited to the following areas today:  
Oral: Significant tartar accumulation is present on the maxillary canines and incisors. An overbite is noted.  
Cardiovascular: Heart and lung sounds are normal on auscultation.  
Respiratory: Heart and lung sounds are normal on auscultation.  
Integumentary: Papules and dermatitis are present on the chin. The hair coat is slightly thin with a dermatitic appearance, but the skin is not significantly erythematous. The skin on the abdomen and feet appears grossly normal.  
Musculoskeletal: Ambulation is reported as normal.  
  
Point of Care Diagnostics:
-   Skin Cytology (tape preparation from abdomen): Revealed normal skin flora with no significant overgrowth of bacteria or yeast.

Assessment
Generalized Pruritus - The patient's pruritus has been poorly responsive to Xenorelial. An underlying allergic skin disease is suspected.  
  
Chin Pyoderma - A secondary bacterial dermatitis is present on the chin. This is likely due to moisture from saliva pooling, which is exacerbated by the patient's dental disease and conformational overbite.  
  
Periodontal Disease - Significant dental tartar is present, which is contributing to the oral bacterial load and subsequent chin dermatitis.

Plan
Medications/Treatments:
-   Cytopoint 10 mg was administered via SQ injection today. The owner was informed this injection is intended to last 4-6 weeks and the cost is $178.
-   Oral antibiotics were prescribed to be given BID for the pyoderma on the chin.
-   A topical anti-pruritic spray was dispensed to be used SID as needed for itchiness. It was recommended to apply the spray to the paws and belly, and for the chin, to spray it onto a gloved hand and rub it in.
  
Additional Discussion:
-   A dental cleaning procedure was strongly recommended to address the periodontal disease and reduce the bacterial load contributing to the chin dermatitis. The owner was informed of a $150 discount available as part of a promotion.
-   A recheck appointment should be scheduled in 4-6 weeks for the next Cytopoint injection. The owner was advised to schedule for 6 weeks but to come in sooner if pruritus returns before then.
-   The owner was provided with educational material regarding Cytopoint and Apoquel.