C09983147 / invoice 10000

Appointment Notes: Licking paws.When did you notice it? 2 weeks agoBehaviour eg scratching? LickingMoist oozing wound? NoOther concern 1:  No???????Other concern 2 (long consult):???????Additional new client questionsBreed?Age????????Batch:Exp:Date of last consult:Primary complaint/relevant information:  Disease onset Progression and duration: Current Medications: None  Medical conditions: None  Appetite: Energy Levels: Exercise/Exercise intolerance: Vomiting: Diarrhoea:  Weight loss/gain: Thirst: Urination: Coughing/Sneezing/Respiratory signs: Diet:  Flea/tick:  Worming: Indoor/outdoor: Toxin exposure: Travel history: Shaking head, pawing at ear/s (Left/Right/Both) Red, swollen, painful ear/s (Y/N)Discharge from the ears (Y/N)Previous ear infections (Y/N)Concurrent skin problems (Y/N) EXAMINATION: Demeanour: BAR MM: Pink, moist, CRT <2 Eyes: Clean and clear, normal eyelids, no erythema or discharge Ears:External appearance: (bilateral brown discharge, erythematous) Otoscope exam: (brown discharge, canal swelling, TMs intact/not visible)Lymph nodes: Peripheral lymph nodes palpably normal Oral: No oral lesions or abnormalities detectedTeeth: Dental grade 0/4, normal occlusion. COHAT Level Estimated: (A, B, C, D, E) Cardiovascular: Normal heart sounds, no murmurs or arrhythmias detected, femoral pulses synchronous and normodynamic Respiratory: No nasal discharge, normal bronchovesicular lung sounds in all 4 quadrants, no coughing seen Abdomen: Soft and comfortable on palpation, no masses palpated, bladder unremarkable MSK: Normal gait no lameness. Normal ROM with no pain of all limbs. No pain on DV palpation of spine Integument: Coat is soft and clean, no ectoparasites detected, no obvious skin lesions or masses Neurological: Normal mentation, no ataxia or CP deficits observed. Full exam not performed Reproductive/Urogenital: External genitalia normal in appearance Rectal: Not performed PROBLEM LIST: N/A DIAGNOSTICS: Cytology:Left ear: ( ) Right ear: ( ) ASSESSMENT/DDX: Otitis externa (L ear/R ear/both ears) Infection type (Bacterial/Malassezia/Mixed) PLAN:MEDICATION: Owner shown how to administer CLIENT COMMUNICATION: Explained importance of recheckExplained prevention/home maintenance requiredTREATMENT: Handouts given: Ear infections Top 10 handout Progress exam booked     Vital Signs    Weight: 5.2;