C09979447 / invoice 10000

Reason: sore ear Subjective: O recently noticed a sore on his R ear and in his groin Bertie is otherwise well, EDUD normally, no vomiting or diarrhoea No major pruritus prior to scratching ear Behaviour/Temperament: Confident, lovely boy FAS Score: 1Relevant Pre-Visit/EMR Information:Objective:HR/PR: 116Temp: not taken MM: pink, moist <2Pulse: normal pulse quality Resp: 20Hydration: wnl  GIT: soft and comfortable palpation U/G: nad Ears: L ear clean externally but yeast 3-5/hpf on cytology, R ear moderate erythema and scabbing of pinna with waxy debris present, would not tolerate otoscopic examination due to discomfort, cytology 7-10/hpf Skin: small pustule present in L groinEyes: clear M/S: ambulating well on all 4, no palpable concerns Dental: deciduous dentition, 704 & 804 appear to be deviating in a more normal position Other: superficial palpable LN wnl Assessment: OE bilaterally Pustule in groin Treatment: Dermotic 0.3mL administered to both ears Cephalexin 100mg PO Pred 2.5mg PO Plan: Continue dermotic both ears BID 7 days Continue cephalexin 100mg BID 7 days Continue pred 2.5mg SID 3 days Revisit 14days - vacc at the time. Revisit sooner if concerns Follow Up Call: Not Required.    Vital Signs    Weight: 3.6;       

Reason: recheck footSubjective: Has been doing well at home EDUD normally, did have a vomit after metacam so O stopped No new concerns Behaviour/Temperament: Confident, lovely boy FAS Score: 1Relevant Pre-Visit/EMR Information:Objective:HR/PR: 124Temp: not taken MM: pink, moist <2 Pulse: normal pulse quality Resp: pantingHydration: wnl GIT: comfortable palpation U/G: nad Ears: clean externally Skin: previous wound RH digit 1 has healed, a small scab is present Eyes: clear M/S: ambulating well on all 4Dental: deciduous dentition, base narrow canines but they are moving more buccally than previous Other: superficial palpable LN wnl Assessment: Skin wound healed well Treatment: Nil in clinic Plan: Plan to remove HL dew claws at desexing consults as neededFollow Up Call: Not Required.    Vital Signs    

Reason: sore on paw Subjective: This morning O noticed blood on RH paw, unsure where from Bertie seems well in himself EDUD normally, no vomiting or diarrhoea No current meds Behaviour/Temperament: Confident, lovely boy FAS Score: 1Relevant Pre-Visit/EMR Information:Objective:HR/PR: 108Temp: not taken MM: pink, moist <2 Pulse: normal pulse quality Resp: 20Hydration: wnl  GIT: comfortable palpation U/G: nad Ears: clean externally  Skin: trauma and skin wound associated with the RH dew claw due to string being attached around the digitEyes: clear M/S: ambulating well on all 4 Dental: deciduous dentition, 704 is base narrow, 804 is growing more laterally Other: superficial palpable LN wnl Assessment: Skin wound associated with RH attached dew claw due to string Treatment: Cleaned area with chlorhex Cephalexin 50mg given PO Plan: Commence metacam 0.25mg SID Continue cephalexin 50mg PO BID Cone on at home Revisit next week Plan to remove HL dew claws at desexing Follow Up Call: Not Required.    Vital Signs    Weight: 2.5;