C10010749 / invoice 10000

Appointment Notes: has irritated L ear, red and inflamed, O has cleaned ear out with solution todayHx-shaking head, red left ear. no more skin diseases. EDUD-wnl. Ex-anxious, muzzled, erythema on left ear, minimal discharge(owner cleaned the ears today with otoflush). ear cytology- yeast ++pmp given for 14 days.     Vital Signs    Weight: 19.1;       

    Vital Signs    

Appointment Reason: Skin hives / rash / eruptions, Appointment Notes: Skin rashes on the belly since last week.HistoryOwner reports a rash on Nala’s belly that developed approximately one week ago. The affected area has progressively worsened, with redness, irritation, and intense pruritus. Lesions have begun to spread caudally towards the abdomen. No other systemic signs such as lethargy, vomiting, or inappetence were reported.Clinical ExaminationMarked erythema and irritation localised to the left ventral thorax , extending towards the cranial abdomen. Lesions present with areas of crusting and scabbing. Mild to moderate localised swelling noted.Patient actively pruritic during examination.No signs of pustules, ulceration, or generalised alopecia beyond the affected zone.Sticky tape impression: Positive for fungal spores.Diagnosis: Localised fungal dermatitis (likely dermatophytosis) with secondary inflammation and pruritus.TreatmentInjections administered Dexapent to provide anti-inflammatory and antipruritic relief. Gentam to assist in controlling secondary bacterial involvement.Dispensed Topizole wash and Fungafite.PlanContinue topical treatments as directed.Monitor for reduction in redness, itching, and spread of lesions.Recheck in 2 weeks to assess healing progression and treatment response.Advise owner to prevent Nala from licking or scratching the area; consider an Elizabethan collar if irritation persists.    Vital Signs    Weight: 18.1;       MMColour: Pink;       RespirationRate: 40;       HeartRate: 104;       Skin: Abnormal;       Heart: Normal;       Lungs: Normal;       Demeanour: BAR;       Hydration: Normal;       BodyScore: 4;       PainScore: 0;       CRT: 1-2;