C09983634 / invoice 10000

Reason: PoC, TSOAppointment Notes: LSWife in hospital at present. Max has been whimpering and yesterday didnt eat unless hand fed. Otherwise BAR EDDU NO V OR DNurse: LF-vaccination UTD-heartworm UTD-worming UTD-flea/ticks UTDHistory: For 9 days POCHas been well vd- vd-Yesterday was whinning and did not eat breakfast readily, needed tobe coaxed but did finish foodVd-Dog's primary carer (Tony's wife) has been away for the past week receiving medical treatment in hospital, suspect Max is experiencing separation anxietyToday still whinning a little but ate breakfast readilyAsked about post op meds - O said compliance was an issue, there were several days when clav was given SID instead of BID.Skin ok, not itchy.  O said cytopoint usually lasts for 2 months. Examination:BAR mm pink no HM normal rate and rhythm BV lung sounds abdo palp nsf sup LN WNLSx sites:Right lateral chest -> fully healed, skin full opposed, no erythema, no bleeding, no discharge, no swelling.  Removed all sutures. Top of head - skin full opposed, no swelling, no bleeding, no discharge.  LHS end of incision is mild inflammed and bit "puffy".  No discharge, not bleeding.  Removed all sutures. Skin:  Overall non inflammed and no pyoderma lesions. Ears  Bot hear pinnae mildly inflammed and also thickened with brown cerumin ++.  Patient does not tolerate otoscopic evaluation. Ear cytology:LHS mal +++RHS mal ++Treatment:Suspect mildly superficial cutaneous infected incision site dorsal head location due to owner non compliance with antibiotics. Bilateral OE - suspect due to ecollar use and dog has underlying atopy.  Rx clav 100mg Po BID 10 daysDermotic BID both ears 10 daysConsent has been given by the client to proceed with this treatment  -  YesPlan:Recheck EC and dorsal head sx site in 10 daysKeep ears dry at all timesDiscussed using cortavance/austrazole for long term prophy after current OE resolved. Reminded top up cytopoint - O said he is on top of that    Vital Signs    Weight: 5.4;       HeartRate: 112;       DentalGrade: 0;       Temperature: not taken;       CRT: 2s;       MMColour: pink;       BodyScore: 3/5;