C10027208 / invoice 10000

13/03/2026 Reason:  
History: 
- In today for cytopoint injection
- O has reported that Duke has been a lot more itchy lately

EDUD: All normal
V+/D+/Coughing: None
Pre-existing conditions: None
Current medications: None
Previous adverse reactions (vacc/meds): None
Prophylaxis: UTD

Examine: **VERY boisterous and whining**
Mentation: BAR
Body condition score:  3.5/5
MM: P/M
CRT: <2s
HR: 100  w/ no murmur or arrythmia auscultated             
RR: WNL w/ no adventitious sounds auscultated
LN: Submandibular, prescapular, and popliteal WNL
Temperature: NE
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Ocular: 
- Difficult to assess as moving around too much
- Third eyelid red and protruding
- Minimal scleral injection
Gastrointestinal: Comfortable abdomen, with no pain noted on palpation. No abnormalities felt.
Integumentary & lumps (measurement, location):
- Severe facial and ear erythema, thickening of skin, and pruritis (scratching face on my leg)
- Moderate erythema on body and legs

Cytology (bilateral ears): malassezia ++ 
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Problem List/Assessment:
- Severe allergic dermatitis
A: Advised course of steroids to bring inflammation and pruritis down and then give cytopoint at revisit.

Treatment: 
- Pred 20mg SID for 7d then taper
- Dermotic BID for 10 days

Plan/Follow-up: 
- RV in 10 days