C09972228 / invoice 10000

REASON: Ears + due Semi-AHC
Nurse: SP
Presented by: Christine
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HOME CARE AND PREVENTIONS
Vaccinations: KC + C3 vx UTD
Nutrition: RC dry
Worming: milbemax
Hwp: proheart
Flea Treatment: nexgard
CE: 
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SUBJECTIVE / HISTORY: 
Shaking head and scratching ears, a couple of scabs present
Not good control of back legs, otherwise walking ok
Growth on nipple a tad bigger
EDUD normally
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CURRENT / ONGOING MEDICATION AND SUPPLEMENTS:
Apoquel 16mg 1/2 tablet SID
HCA Spray 0.5ml to each ear on 2 consecutive days each week
Isaderm when needed for skin flare ups
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OBJECTIVE / EXAM:
ASA Status (1-5): {__}
BCS (1-9): {__}
DS (0-4): {__}

T: -
P: {__}
R: n

APPEARANCE/DEMEANOUR: BAR
SKIN & COAT: n
EARS: Red externally both ears, more debris in L ear
Ear cytology R ear - Cocci + paired cocci+++
L ear - Cocci++
EYES: n
ORAL: {__}
MM: Pink, moist
CVS: Normal rhythm
RESP: Lungs clear
ABDO/GIT: n
UROGEN: n
NEURO: n
MSK: n
LN: n
n : Normal     - : Not Examined
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ASSESSMENT: 
Problems:
{__}

Ddxi:
{__}

Further Procedure & Diagnostic Needs [Client Response]:
Estimate lump removal (d) awaiting ear infection to resolve first

Medication:
Easotic 1 dose to both ears SID (x)

Ongoing medication prescriptions? Renewed prescriptions: {__}
[a] = Appointment     [d] = Deferred     [w] = Waived     [x] = Do it now
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PLAN / CE: 
Rev 5 days recheck ears + book in lump removal
Rem KC + C3 + Proheart + AHC July 2026
Finalised by {__}
Rec = Recall     Rev = Revisit     Rem = Reminder

Slept not too bad during the night, couple of coughs. Gave toast this morning and ate that well, and ate his kibble . No v+. Tried to clear throat a few times, breathing okay but quieter. Monitoring him for now, home all day with him. Will let us know if any concerns

History received from SASH