C09985896 / invoice 10000

Right forelimb lameness
Unable to examine conscious 

Subjective:
- Presenting for assessment of ears.
- Owner reports recent swimming and increased washing, which may be contributing.
- No other pruritus noted (paws, belly).
- No vomiting or diarrhoea reported.

Past Medical History:
- recurrent ear infections last one about 6months ago

Objective:
BAR
mm p&m crt <2
hr wnl no murmur auscultated
both ears moderate amount of brown discharge in ear canal, minimal to no erythema. cytology - +++malassezia both ears, left worse than right
cleaned ears with epitoic

Assessment:
- Diagnosis: Ear infection.

Plan:
- Treatment planned: dermotic 0.7mL to be administered to each ear twice daily for 10 days.
- Recommendations and counselling: Owner counselled on medication administration technique, including managing the viscosity of the liquid and massaging the ear canal post-application. Advised that syringes can be washed and reused.
-  Recheck consultation scheduled in approximately two weeks to confirm resolution.

Locum Veterinarian Dr Zoe Blum BVSc NSW 11220

Patient Information:
-   Male dog
-   Examination date: 11/03/2025

Subjective:
-   Presents with vomiting , last few containing blood
-   No changes in energy levels
-   No exposure to new products, garden changes, or unwell dogs
-   Attends daycare once weekly on Thursdays
-   Vaccinations up to date
-   No further vomiting or retching since morning episode

Objective:
-   Temperature: Normal
-   Heart and lung sounds: Normal
-   Gum colour: Normal
-   Abdomen: Mild discomfort on palpation of upper abdomen. Lower abdomen soft, no masses palpated
-   Ears: Previously treated, currently stable

Assessment & Plan:

1. Vomiting
-   Likely gastritis/gastric irritation
-   Differential considerations: oesophageal irritation, gastric ulceration, coagulopathy (less likely)
-   Plan:
    -   Gastric protectant medication commenced - one tablet daily
    -   First dose tonight at 17:00, feed at 18:00
    -   Monitor for continued vomiting
    -   If symptoms persist: blood tests and imaging to be considered
    -   Review if vomiting continues or condition deteriorates