C10029317 / invoice 10000

Red irirtation where harness rubs
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Insurance ()
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**HISTORY**

Owner reports: Rash under right axilla noticed 2-3 days ago. Licking and chewing incessantly at the area. Restless at night. Harness has not been used for last couple of days. No previous skin problems. Occasional paw chewing but not excessive. Sensitive stomach - chicken causes irritation.

Otherwise eating drinking, urinating and defaecating normally. No known vomiting or diarrhoea.

Owner has no other concerns.

Recent medication: Nil reported.

PRIMARY PROBLEM: Right axillary dermatitis with pruritus.

**EXAMINATION**

Hydration normal, mm=pink, CRT=normal
Eyes: NAD
Ears: NAD
Nasal exam: NAD

Oral exam
- Dental grade: Not assessed
- Dental conformation: Not assessed

Lung auscultation: NAD, no dyspnoea present
Cardiac auscultation: NAD, Heart rate appropriate and regular, no arrhythmia, HR=PR, femoral pulses strong and synchronous
Murmur auscultated: No murmur present
Abdominal palpation: Relaxed and comfortable on cranial abdominal palpation, no pain response
Integument: Right axilla - erythematous, welt-like lesions present, pruritic. Remainder of coat NAD, non-pruritic.
Ectoparasites: None seen, tick search negative. Tick and flea control up to date.
Musculoskeletal: Orthopaedic exam NAD, ambulating well
Neurological assessment: NAD
Lymphatic system: All peripheral LNs palpate normally with regards to size
Urogenital system: NAD
Rectal palpation: None performed
Anal sac: Not examined

Weight: 7kg

**ASSESSMENT**: Right axillary dermatitis - likely contact reaction or insect bite. Does not appear consistent with harness friction/chafing. Possible plant contact or insect bite with secondary self-trauma from licking and chewing.

**PLAN**:
- Tapering oral cortisone course: Half tablet twice daily for 3 days, then half tablet once daily for 3 days, then half tablet every second day for 1 week.
- Avoid harness until resolved - use lead around neck for walking.
- Wash harness in case of plant material or fabric irritation.
- Monitor for increased thirst and appetite (potential side effects of cortisone).
- Recheck in 2 weeks.
- Return earlier if not improving.