C09982019 / invoice 10000

Reason:  check ears 
History: 
R ear seems very irritated - red and gunky 
Had a bit of trouble defaecating this AM - scooting a little afterwards 
No D+
EDUF good 

Current medications: none 

Examine: 
Mentation: 
Body condition score: 
MM:                CRT: 
HR:                RR: 
LN: 
Temperature: 

Ocular: 
Oral/Dental stage:
Ears: 
Cardiovascular: 
Respiratory: 
Gastrointestinal: 
Integumentary & lumps (measurement, location):
Musculoskeletal: 
Urogenital: 
Neurological: 

Problem List:

Assessment: 

Treatment: 

Plan: 

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

Followup: 

Presented for annual vaccination
O concerned about her fear aggression. recently has bit a dog who came to their property 


Examine: 
Mentation: BAR, very nervous, did not try to bite 
BCS:                           3/5   
MM: Pink          
CRT: 1-2 seconds
HR:                     124        beats/min
RR:                       32      breaths/min
Dental Stage: did not tolerate a thorough oral exam. stage 2 
Gastrointestinal: No masses or abnormalities noted on palpation
Integumentary: No significant abnormalities noted during routine physical examination
Musculoskeletal: No evidence of lameness
Additional findings: EENT wnl 

Assessment: healthy for vaccination

Treatment: nil
Vaccination given: KC
Vaccination due next year KC
Batch number:


Discussed behavioral training vs medication (fluoxetine). o not interested in either option today 

Reason: Courtesy phone call post surgery/ procedure
Nurse:rh
History:post sedation and nail r/o
     Demeanour:bar
     Eating/ Drinking:y
     Toileting:y
     Any concerns?n

Treatment:
     Medications being given:carprofen
     Patient taking meds as prescribed?y

Assessment:going well, no concerns

Next Appointment:bandage r/o