C09982379 / invoice 10000

SUBJECTIVE HISTORY: O reports dog has improved but is still scratching intermittently at the R ear. EDUD all NAD. Vaccination status: DueOBJECTIVE EXAMINATION:Mentation: BAR, BCS: 4/9Hydration: MM pink & moist, CRT <2sDental: Gr 0.5/4 periodontal diseaseOral exam: NADEyes: Clean & NAD. Full ophthalmologic exam not performedEars: Clean externally, NAD. Otoscopic exam of both ears NAD, TMs intact, no discharge or FB identified (had CC second opinion verify too)HR: normal rhythm, no murmur detectedRR: regular, NAD on chest auscultation, normal effortAbdominal palpation: NAD and comfortableInteg: Skin and coat healthy, no obvious lesions or lumps noted, normal skin recoilMusculoskeletal: No obvious limping noted.Peripheral LNs: WNLNeurological: BAR. A full neurological exam not performed.LABORATORY:Cytology of both ears NADASSESSMENT/DDx:No infection or FB present in ears but dog still occasionally scratching at R ear - potential underlying skin allergyTREATMENT:- Protech C4 vaccination SC- Protech Bronchishield oral vaccination- Cytopoint 40mg/ml - 0.25ml SCPLAN:Trialing Cytopoint inj for pruritis, revisit if no improvement.The intention of the following template is to clarify the minimum requirements for veterinary notes. This should not be used if it is a first claim as it will likely go on hold for more information required. GapOnly claim Insurance Summary  First Clinical Signs: Approx 2 weeks ago scratching/shaking R ear.Summary: Treated for Malassezia otitis externa with Dermotic, rechecking today to determine if ear clean needed. Otoscopic exam NAD. Also due for vacc.Diagnosis: Resolved otitis externa but dog still scratching at ears, potentially underlying atopy causing irritation. Treatment: Cytopoint 40mg/ml - 0.25ml SCProtech C4 vaccination SCProtech Bronchishield oral vaccination

Recheck earsHISTORY: O reports that the dog is still frequently shaking her ear. EDUD all NAD. O thinks dog scratched her side on building equipment in yard.EXAM: BAR. MM pink and moist, CRT <2s. Cardiac and thoracic auscultation NAD. Abdominal palpation NAD. Dentition NAD. Otoscopic exam of ears: L ear NAD, R ear shows ointment in distal canal. LABORATORY:Cytology of both ears show occasional MalasseziaASSESSMENT: Malassezia in both ears now. Due to ointment presence cannot visualise R TM or previous possible FB. PLAN: Treat both ears with Dermotic BID for 3 days, then cease treatment. Recheck in 1wk fasted incase requires ear flush.The intention of the following template is to clarify the minimum requirements for veterinary notes. This should not be used if it is a first claim as it will likely go on hold for more information required. GapOnly claim Insurance Summary  First Clinical Signs: One week shaking ear and wound on side, seen in consult last week. Summary: Improving but not resolved otitis externaDiagnosis: Otitis externa with Malassezia, but due to ear ointment cannot visualise TM.Treatment: Continue Dermotic but in both ears for another 3 days. Recheck in 1wk, fasted incase ear clean required.

SUBJECTIVE HISTORY: O noticed wound on dog's hip today around midday - dog licking the area. Shaking ears for 2 days. EDDU all NAD. Not had ear infections before and not usually pruritic.OBJECTIVE EXAMINATION:Mentation: BAR, BCS: 4/9Hydration: MM pink & moist, CRT <2sDental: Gr 0/4 periodontal diseaseOral exam: NADEyes: Clean & NAD. Full ophthalmologic exam not performedEars: R ear shows mild erythema and excoriation in external canal. L ear NAD. Otoscopic exam of R ear shows mild erythema and swelling and a small brown object less than a match stick head in size (wax? part of plant material?) unfortunately is against the ear drum. L otoscopic exam NAD.HR: normal rhythm, no murmur detectedRR: regular, NAD on chest auscultation, normal effortAbdominal palpation: NAD and comfortableInteg: On the L hip area there area a few small excoriated papules (6-8) and mild erythema. Musculoskeletal: No obvious limping noted.Peripheral LNs: WNLNeurological: BAR. A full neurological exam not performed.LABORATORY:- Cytology of L ear NAD, R - ear Malassezia++- Sticky tape impression of affected area on L hip: neutrophil nuclear streaming+, occassional cluster of intracellular cocciASSESSMENT/DDx:- Bacterial dermatitis on L hip - unknown underlying cause - O reports dog playing rough with other dog at park - wound?- Malassezia otitis externa in R ear with potential very small FB or waxTREATMENT:- Clipped hair over lesion on L hip and cleaned with chlorrhexidine, O to continue SID cleaning for a few days (chlorrhex/iodine solution)- Cephalexin 100mg PO BID for 10 days- Dermotic 0.5ml in the R ear BID for 1 wkPLAN:Recheck in 1wk. If small FB/wax clump still present then will need sedation for attempted removal due to close proximity to TM.The intention of the following template is to clarify the minimum requirements for veterinary notes. This should not be used if it is a first claim as it will likely go on hold for more information required. GapOnly claim Insurance Summary  First Clinical Signs: Today at midday licking rump. 2 days shaking ears. Summary: Red, excoriated area on L lumbar area. Erythema externally in R earDiagnosis: Mild bacterial dermatitis on dorsal lumbar area on L side. Mild malassezia R otitis externa, possibly small amount of wax/FB in ear (less than match head size)Treatment: Dermotic 0.5ml in R ear BID for 1 wk. Cephalexin 100mg PO BID for 10 days. Recheck in 1wk.