C10027689 / invoice 10000

Appointment Notes: Luna (Dog) - Consultation (illness, check-up etc) [Veterinarian : Dr. Julian Sze (Preferred Clinician)] - Need new prescription for ilium neocortWeb BookingClient name: Jeffrey ValleContact number: 61401738043Email address: jeffrey.b.valle@gmail.comPatient name: Luna Original Appointment Type: Consultation (illness, check-up etc)?????HISTORY:Presented for a belly rash, owner requesting more Neocort as this usually helps with flares (dispensed at south yarra vet)Rash flares up seasonally after contact with wet grass. She doesn't lick or scratch however.EDDU normally, no VDCSOwner also noted a small lump on the belly and a scab on the right forepaw, both noticed a few weeks ago and have since reduced in size.Concerned about hair thinning on chest and axilla.Past history: TPLO surgery October 2025, recovering well with ongoing hydrotherapy and physiotherapy.Diet -Prevention - UTD - product not specifiedMeds - Hydrotherapy and physiotherapy for post-TPLO rehabilitation.EXAMINATION:BAR, T38.0, HR100, RR, BCS /9Oral: good dental health, mm PM, CRT <2sEyes: NAD.Ears: NAD.Nose: NAD.LN's: no lymphadenomegaly of peripheral LNsInteg: Erythema and papules on ventral chest, axilla and abdomen, consistent with superficial dermatitis. Lesions blanch on pressure. No pustules. Mild hypotrichosis of chest and axilla. Small, soft, non-painful subcutaneous mass on ventral abdomen. Resolving superficial lesion on dorsal aspect of R forepaw digit.Neuro: NAD, full exam not performedMSK: ambulating normally, WBx4Resp: normal BV sounds, normal respiratory effortCVS: no murmurs, normal rhythm, intensity, SSFPAbdo: soft and comfortable, no organomegaly palpable.Urogen: NAD.DIAGNOSTICS:FNA of abdominal mass: greasy, pale, thick material. No live cells seen. Consistent with an impacted gland.Skin cytology: significant bacterial overgrowth noted.PROBLEMS:Superficial pyoderma secondary to allergic contact dermatitisSubcutaneous abdominal massPost-TPLO recoveryASSESSMENT:Ventral dermatitis: primary allergic reaction to grass with a secondary superficial bacterial infection (pyoderma).Abdominal mass: cytology suggests an impacted gland. Mast cell tumour considered less likely.R forepaw lesion: likely resolving ingrown hair.TREATMENT:Pyohex Medicated Shampoo (3% chlorhexidine) - bathe every second day for 1 week, then twice weekly for 2 weeks. 10 minute contact time required.Pyohex Leave-in Lotion - apply to affected areas morning and night for 14 days.Prednisolone - 1/2 tab PO SID for 5 days, then 1/4 tab PO SID for 3 days, then 1/4 tab PO EOD until finished.Fine needle aspirate of abdominal mass performed.PLAN:Recheck in 2 weeks to repeat skin cytology.Avoid grass until skin infection has resolved.Ensure skin is dried thoroughly with cool air after bathing or becoming wet.Once infection is clear, use Aloebean shampoo for maintenance bathing.Monitor FNA site for any changes.A maintenance steroid spray to be prescribed for future flare-ups, to be used for a maximum of 10 days at a time.If seasonal dermatitis persists/worsens, consider referral to a dermatologist for allergy testing and immunotherapy.COMMUNICATION:Discussed likely cause of rash is contact allergy to grass with secondary bacterial infection.FNA findings suggest lump is an impacted gland and likely benign.Explained importance of 10-minute contact time for medicated shampoo and tapering dose for prednisolone.Advised on potential side effects of prednisolone (polyuria, polydipsia, polyphagia).Discussed long-term management strategies including maintenance shampoos and potential specialist referral.Advised to cease use of expired combination antibiotic/steroid cream.?????    Vital Signs    Weight: 17.1;