C10011577 / invoice 10000

Reason: SkinAppointment Notes: Booked Online: 07/03/2026 16:46:31 PMBooking Type: Skin, Ears, Eyes or LumpsBooking Notes: Hair loss patch and flakey skin Owner Name: Hayley MacleodOwner Email: hayleymacleod.seda@gmail.comOwner Mobile Number: 0422313455Pet Name: CaoimhePet Species: DogWeb BookingClient name: MacleodContact number: 0422313455Email address: hayleymacleod.seda@gmail.comPatient name: Caoimhe  ------- Sms reply: YesReason:(Assisted by: )HISTORY:  Presented for a skin lesion. The owner noticed a flaky, alopecic area since yesterday.Eating and drinking habits are normal.There is a history of another household dog scratching humans and jumping onto patient's back during excitement, raising the possibility of trauma from dirty nails introducing bacteria and causing the skin irritation. Current meds: noneVaccination: UTD.Parasite Prevention: UTD.Pre-existing conditions: noneAccess to toxins eg. Rodenticide: none EXAMINATION:Body Condition Score: 6/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateNeurological: neurologically no observable findingsMusculoskeletal: ambulating normallyIntegument/Ears: A focal, circular area of flaky, mildly irritated at edges, and alopecia was noted. The area of concern is approx 35 mm diameter. The area is located on the dorsal surface of approx T11 region. The rest of the coat and skin appears normal. Paws appear normal.Lymph Nodes: NSFEyes: NSFDemeanour/Behaviour: BAR, anxious but compliant on exam after group hug PROBLEM LIST:Focal dermatitis with flaking and inflammation. DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Potential diagnoses included zoonotic/infectious causes (e.g., ringworm), parasitic causes (e.g., mites), or a bacterial infection, possibly secondary to trauma. DIAGNOSTICS:Wood's lamp examination of the affected area was negative for fluorescence.Tape impression cytology and skin scraping were performed.Microscopy ruled out parasitic involvement.Some bacteria were identified; it is undetermined if this is the primary cause or a secondary infection. ASSESSMENT:Keeva presented with a focal area of dermatitis. Diagnostic workup including Wood's lamp, tape cytology, and skin scraping was performed. Ringworm and mites were ruled out. Bacteria were present, but their role as a primary or secondary agent is unclear. The possibility of a trauma-induced bacterial infection is considered. TREATMENT:  A neocort topical cream with antibacterial and anti-inflammatory properties was dispensed.Apply to the affected area twice daily for the next three days. PLAN:Monitor the lesion for improvement. Re-evaluation is required if the lesion increases in size or if fur loss spreads.A skin biopsy may be considered in the future if the condition does not resolve or worsens.Home into owner's care. CLIENT COMMUNICATION:Discussed examination findings and results of initial skin tests, explaining that parasites and ringworm are unlikely.Advised on the application of the dispensed topical cream.Instructed the owner to monitor for improvement, specifically the growth of new hair.Advised to return if the lesion worsens, spreads, or if new areas of fur loss appear.Mentioned that further diagnostics, such as blood tests or a skin biopsy, may be necessary if the condition persists.    Vital Signs    Weight: 22.05;