C10013458 / invoice 10000

Reason: Hot SpotsAppointment Notes: ------- Sms reply: YReason: Client Present:Nurse:Healthy Pets Wellness Testing: Done Yes / NoVaccination Type:utdIntestinal worming:utd spectra Heartworm Prevention: utdFlea Prevention: utdTick control: utdMicrochip: yesInsurance and Healthy Pets Plus: HPP (has insurance but doesnt want to put a claim through)Behaviour concerns: noCurrent medications:__________________________________________________________________________HISTORY:Diggy presented for follow-up of hot spot that has been ongoing. Owner reports the hot spot appears to be improving but still has purulent discharge and odour. Previously treated with antibiotics (Amoxyclav) and steroids which brought down inflammation. Owner notes Diggy is scratching a little but this is normal for him. Another hot spot on his bottom has healed and scabbed over with hair growing back.Current meds: noneVaccination: Not mentionedParasite Prevention: Not mentionedPre-existing conditions: Recurrent hot spots, allergic dermatitisAccess to toxins eg. Rodenticide: noneEXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): not graded- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: Hot spot present with purulent discharge and odour, no superficial skin infection identified on examinationLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: not discussedPROBLEM LIST:Persistent hot spot with purulent dischargeSuspected deeper skin infectionRecurrent hot spots suggestive of allergic dermatitisDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Deep pyodermaAllergic dermatitisDIAGNOSTICS:Impression smear performed - no superficial skin infection identifiedASSESSMENT:Diggy presented for follow-up of hot spot. Despite previous antibiotic treatment with Cephalexin and steroids, the lesion continues to have purulent discharge and odour. Examination and impression smear ruled out superficial skin infection. Concern for deeper tissue invasion causing delayed healing. Recurrent hot spots suggest underlying allergic dermatitis.TREATMENT:Cephalexin 600mg prescribed for 10 days to target potential deeper skin infectionChlorhexidine wipes provided for twice daily cleaning of affected areaSteroids discontinuedPLAN:Recheck in 10 days (around 28/03/2026)Consider anti-allergy medication (Cytopoint injection or oral medication) if current treatment insufficientMonitor response to new antibiotic regimeCLIENT COMMUNICATION:Discussed concern for deeper skin infection despite resolution of superficial infection. Explained rationale for changing antibiotic and continuing topical cleaning. Advised to monitor progress and return for recheck before owner's travel on 28/03/2026. Insurance claim to be submitted for treatment costs.    Vital Signs