C09979414 / invoice 10000

03/03/2026 
Reason/concerns:  ear infection 

History:
- Head shaking a few ay ago. 

- EDUD: normal
- No V+ or D+
- no other concerns at home 

Pre-exisitng Conditions / Medications: 
- Had one AG removed in 

Examine: 
Mentation: BAR
BCS:                    5       /9   
MM: Pink          
CRT: 1-2 seconds
HR:                     95        beats/min
RR:                    pant         breaths/min
Temperature:        not taken      degrees Celsius

Ocular: No abnormalities noted on cursory examination of both eyes.
Oral/Dental stage: Moderate gingivitis and calculus observed. 
Ears: Minimal external discharge or inflammation. 
Cardiovascular: No audible murmur or arrhythmia and no difficulty hearing the heart. HR = PR and no evidence of hypoperfusion.
Respiratory: Respiratory rate and effort considered normal for the patient.
Gastrointestinal: No pain on abdominal palpation. No masses or abnormalities palpated.
Integumentary: No significant abnormalities.
Musculoskeletal: Normal gait and strength noted. No evidence of lameness.
Urogenital: No significant abnormalities noted during routine physical examination.
Neurological: No evidence of neurological impairment or altered mentation. Detailed neurological examination not performed today.
Lymph nodes: Within normal limits for mandibular, prescapular and popliteal examination.

Problem List:

Patient Assessment: 

Diagnostics performed (i.e. bloods, radiographs/ultrasound, ear cytology, urinalysis):
Bilateral mild erythema and discrage in internal ear canal 
- L: malassezia ++, cocci ++ 
- R: 

Treatment with medication dose rates (if any):
- Dermotic twice daily for 10 days 
- Otoflush twice daily for 10 days *O has both at home 
- Nail clip and AGs in consult 

Client Communication & Plan: 
- Recheck in 10days to assess if OE is resolved. 
- If out of demotic O to call and we can dispense
- DIsusssed ongoing maintnace

- ears check 
- nail clip 
- AGs 
- over due vac 

On-going medications required: Y/N (use prescription tab for further supply):

Next check up date: