C09974428 / invoice 10000

HISTORYPrimary reason consult: Left ear irritationConcerns: Thick dark discharge from left ear, redness, scratching, dried scabHistorical conditions: BOAS surgeryVacc due: Vaccinations dueWorming/ flea/tick: NexGard Spectra (UTD) changing to quantumCurrent medications: NoMentation at home: BAREDDU: eating & drinking normal, urination and defection normal, No vomitingSkin: Mild itching on feet, manageable pruritus, redness of face with occasional itchingLumps: few skintagsMobility: no pain, no lameness, no ataxiaRisk Factors: Rescue dog, French Bulldog breed, allergiesPHYSICAL EXAMCondition: healthy bodyweightMentation: BARMobility: ambulating well, no lameness or ataxia observed, no abnormalities on palpation of joints and musculatureHR/PR: clear on auscultation bilaterally, regular and strong pulseLungs/RR: lungs clear on auscultation bilaterally, normal breathing sounds and effortTemp: not taken, in good healthMM: pink, moist, CRT<2secTeeth: appropriate bite, clean, no gingivitisEyes: normal appearance of eye and eyelids, normal pupillary responsesEars: Left ear - narrow ear canal, little bit of black wax lining canal, little bit more discharge. Right ear - normal appearance, much cleaner, very much like normal earSkin/Coat: Mild redness around muzzle, ears and feet. Mild redness and staining with black discharge between digits on feet. Abdomen skin looks goodLnn: no enlargement palpable externallyAbdom palp: soft and comfortable, no masses or organomegally notedOther problems found: - Interdigital redness and black discharge on feet- Mild allergic skin condition affecting ears and feetPROBLEM LIST- Left ear infection with bacterial overgrowth (cocci)- Mild allergic dermatitis affecting ears and feet- Interdigital dermatitisDIFFERENTIALSAllergic skin condition with secondary bacterial infection in left earTESTS- Ear swabs from both ears - left ear showed little bit of cicci, right ear normal- HW test negativePLAN- cortavance ears and feet- Heartworm test if wanting annual injections- Annual flea/tick and heartworm injections offered- VaccinationsCLIENT COMMUNICATION- Explained allergic skin condition common in French Bulldogs in Queensland environment- Instructions for steroid spray use - 1-2 pumps per foot once daily, daily dose in left ear for few daysTREATMENT- Quantum right shoulder- Heartworm test negative, SR12 left shoulder- Cortavance dispensed for ears and feet- DHP + KC inj mid neck    Vital Signs    Weight: 12.5;