C10014483 / invoice 10000

Current diagnosis:
Current status:
Current treatment plan:
Current diet:
Other medical history:

History
Age of onset: Aug 2024. Progressing pruritus, otitis and sneezing. Diagnosed with rhinitis
after CT and rhinoscopy at Animalius. Treatd with cetirizine 50mg once a day with
improvement to pruritus and sneezing but not otitis. Treated by VDS with keto/dex and
enro/dex/keto then maintained on keto/dex weekly with good improvement. Was also
treated with doxycycline and amoxyclav for secondary bacterial rhinitis
Seasonality: non seasonal
Lesions: otitis
Distribution: ears
Gastrointestinal signs: nil
Any affected in contact/related pets and humans: one cat no skin issues
Environment:
Indoors: 100%
Previous treatment and response: see above
Diet: bisuits
Previous elimination diet: nil
Other medical history: nil
Physical examination: left ear uncomfortable to examine; right ear focal ceruminous
material horizontal canal;

Recommended diagnostic tests
Sedation for video-otoscopic exam, cytology of skin and ears
+/- general anaesthesia for video-otoscopic flush and examine ear drums for healing
Blood for complete blood count and biochemistry FWP


Diagnosis
Itchy skin and ears with allergic rhinitis due to environmental allergy
Mould hypersensitivity
House dust mite hypersensitivity
Storage mite hypersensitivity
Insect bite hypersensitivity
With or without concurrent food allergy
Bilateral wax plugs due to loss of self cleaning mechanisms
Unilateral left otitis media (perforated ear drum)

Treatment plan:
1.Symptomatic anti-itch therapy
Continue antihistamines; cetirizine 10mg tablets; 5mg orally twice a day. 
Try reducing prednisolone 5mg/ml; 2.5mg (0.5ml) orally once a day for 14 days reducing to 2.5mg (0.5ml) orally every 2nd day for 14 days reducing to 1.5mg (0.3ml) orally every 2nd day until revisit
We have discussed expected side effects including hunger, thirst and increased urination. Stop if these side effects are unacceptable
2.Symptomatic antimicrobial therapy
Nil required
3.Elimination diet for food allergy
Continue novel protein and carbohydrate using VNG receipe (remove the omega oils) for 6 to 8 weeks
https://www.vngpets.com/pages/feeding-guide-for-cats-with-food-sensitivities
Do gradual change over from current diet over 3-5 days to avoid potential
gastrointestinal upsets
4.Allergen specific immunotherapy
Commence induction phase 
We have discussed monitoring for potential side effects after every injection including increased itching, hives, vomiting, diarrhea and anaphylaxis.
The allergy vaccine is the only treatment modality that can modify the underlying
allergic disease, reduce overall itch level, control against reinfections and reduce the
amount of anti-itch medications required. The vaccine will take up to 6-9mths to take
effect and we have a 70% success rate. If Mia improves, then she will stay on the
vaccine for about 3 years to maximise the efficacy
Mould/house dust mite avoidance
https://www.allergy.org.au/patients/allergy-treatment/allergen-minimisation
Storage mite avoidance: keep any dry food in airtight containers and freeze overnight
Insect avoidance: avoid areas of high insect activity. 
5.Ear therapy
Both ears: continue Otoflush 0.5ml once a week
6.Calming medications
Continue gabapentin 100mg capsules; 100mg orally the evening before and again 2hrs before revisit. Script written

Revisit: We would like to see Mia in 6 weeks
Future plan:
1.Mia has been more itchy and the prednisolone has helped reduced the overall itch. We will try to reduce the prednisolone to the lowest dose required.
2.We have discussed sedation to examine the ears and perform blood monitoring for the elevated liver enzyme (ALT). If Mia becomes irritated to her ears, we can proceed to general anasthesia to flush the ears to examine the ear drums and checking healing of the perforation.

Intradermal testing revealed strong positive reactions to grasses, weeds, tree pollens, mould spores, house dust mite, storage mites and insect bites.
We will await the blood Heska allergy test results available in 4 weeks before combining both results to formulate an allergy vaccine for Mia. We will continue antihistamines and have on standby prednisolone to be given if Mia flares in her skin/ears and/or rhinitis.
2.Using the video-otoscope, both ear canals had wax plugs adherent to the ear drums. We managed to gently flush them away to reveal a small perforation to the left ear drum. The right ear drum is intact.

History
Age of onset: Aug 2024. Progressing pruritus, otitis and sneezing. Diagnosed with rhinitis after CT and rhinoscopy at Animalius. Treatd with cetirizine 50mg once a day with improvement to pruritus and sneezing but not otitis. Treated by VDS with keto/dex and enro/dex/keto then maintained on keto/dex weekly with good improvement. Was also treated with doxycycline and amoxyclav for secondary bacterial rhinitis
Seasonality: non seasonal
Lesions: otitis
Distribution: ears
Gastrointestinal signs: nil
Any affected in contact/related pets and humans: one cat no skin issues
Environment:
Indoors: 100%
Previous treatment and response: see above
Diet: bisuits
Previous elimination diet: nil 
Other medical history: nil
 
Physical examination: left ear uncomfortable to examine; right ear focal ceruminous material horizontal canal;
 
Diagnostic test results
Cytology:
Left ear: very occasional Malassezia/HPF
Right ear: 3-5 Malassezia/HPF

Recommended diagnostic tests
Sedation for intradermal and blood Heska allergy testing
Cytology of nose/nasal passages
+/- bacterial culture and extended antibiotic susceptibility testing
+/- upper respiratory viral screening (herpesvirus, calicivirus, chlamydia)
General anaesthesia (with anaesthetist) for video-otoscopy exam and flush/removal of wax left ear +/- right ear
+/- blood (complete blood count, biochemistry; FWP), urinalysis and culture as baseline if we need to commence oral and recommence topical cortisone ear drops
 

Diagnosis
Itchy skin and ears with allergic rhinitis due to environmental allergy
With or without concurrent food allergy 
 
Treatment plan:
1.Symptomatic anti-itch therapy
Can increase antihistamines; cetirizine 10mg tablets; 5mg orally twice a day. Stop at least 7 days before allergy testing
2.Symptomatic antimicrobial therapy
Continue to withdraw doxycycline and amoxyclav
3.Elimination diet for food allergy
Commence novel protein and carbohydrate using VNG receipe (remove the omega oils) for 6 to 8 weeks
https://www.vngpets.com/pages/feeding-guide-for-cats-with-food-sensitivities
Do gradual change over from current diet over 3-5 days to avoid potential gastrointestinal upsets
 4.Allergen specific immunotherapy
We have recommended allergy testing to identify airborne allergen so that we can formulate an allergy vaccine to desensitise against these allergens.
The allergy vaccine is the only treatment modality that can modify the underlying allergic disease, reduce overall itch level, control against reinfections and reduce the amount of anti-itch medications required. The vaccine will take up to 6-9mths to take effect and we have a 70% success rate. If Mia improves, then she will stay on the vaccine for about 3 years to maximise the efficacy
5.Ear therapy
Withdraw ketoconazole/dexamethasone to ears for now
6.Calming medications
Continue gabapentin 100mg capsules; 100mg orally twice a day the day before and again 2hrs before revisit. Script written
 
Revisit: We would like to see Mia for the above procedures
Future plan:
1.Mia has itchy skin and ears with allergic rhinitis due to underlying environmental with or without concurrent food allergies. The itching results in secondary infections, further increasing the overall itch level. We would need to manage both allergies for best long term outcome.
2.There is a small wax plug in the left ear and the right ear is irritated and inflamed. We recommend video-otoscopic removal of the wax plug.
3.To manage the itchy skin due to environmental allergy, we will continue antihistamines. For longer term management, we recommend allergy testing and vaccine.
4.Some cats can have a concurrent food allergy and we have recommended starting an elimination diet to investigate for this. We have discussed crocodile and chicken cross react.

Reason: Vaccination
History: 
EDUF: normal
V#/ D#/ Coughing? no

Current medications:

What Preventative health cover is being used and do you need to purchase any today? 
Worming:
Flea control:
Heartworm Prevention:
(TWP discussed: Yes/No)

Examine: 
Mentation: bright and alert
BCS (0-5):        3.5
MM:    pink              CRT:1
HR:    160  nervous               RR:28
Dental Stage:0-1
Temperature: 38.1
Gastrointestinal: n
Integumentary: n
Musculoskeletal:
n
Any additional findings:none

Assessment: fit to vacc

Treatment: F3

Vaccination given: F3
Batch number:3254002
Annual vaccination needed:F3