C10028104 / invoice 10000

History
Presenting problem: Licking paws, consistent with allergies. The owner reports licking of the front and back paws. There is pink skin irritation and red saliva staining on the fur esp R antebrachium. 
There is also a history of vomiting approximately once a week, typically in the morning on an empty stomach since he was last groomed a few weeks ago
Eating: Normal appetite.
Drinking: Normal.
Urinating: Normal.
Defecating: Normal.
Any V+/ D+/ coughing/sneezing: Vomiting approximately once per week, usually in the morning on an empty stomach. No contents in vomit- just clear fluid.
Any current medication? None.
Any other concerns: Had a vaccine reaction last year but was fine after vaccination this year.
Physical Examination:
Mentation: BAR
Eyes: NAD
Ears: NAD
Nose: NAD
Mouth: ds 1/4 with some tartar present, MM pink, CRT <2s
Heart: HR 120bpm, regular rhythm, no murmur, pulses good
Lungs: NAD
Abdominal examination: NAD
Skin and coat: Pink skin irritation and red saliva staining on all four paws consistent with allergic dermatitis.  Small scabbing lesion, poss early hotspot R antebrachium
LN: NAD
Temp: not taken
BCS 5/9:
MCS: A/D
Weight: 4.4 kg
Assessment:
Allergic dermatitis (pruritus of the paws).
V+
Treatment:
0.22ml dexapent (5mg/ml Dexamethasone)
Fur clipped around hotspot/area irritation
Plan:
Prednisolone liquid 5mg/ml: 0.5 ml once daily with food for three days, then every second day for three doses (total of six days). Start tomorrow night. Advised that increased drinking  and urinating is a common side effect.
Bacticorten B: Apply twice daily to affected areas for 10 days. Advised to prevent licking for 15 minutes after application.
Re-check not required unless symptoms worsen or do not resolve.
Advised a small bedtime snack to prevent vomiting.