C09986344 / invoice 10000

History: Oreo is a dog who was presented today for ear discomfort. The owner reports that a few days ago, the dog was rolling in the grass. When the owner rubbed behind Oreo's ear, the dog jumped. Initially, Oreo seemed to enjoy the rubbing, tilting his head into it as if it provided relief, but then became agitated. The owner has looked in the ear but could not see anything abnormal. OBJECTIVE:- Physical Exam:- General Appearance: Bright and alert.- EENT: Otoscopic examination of both ears was performed. Both ear canals appeared similar. There was a small amount of waxy debris present, but no significant inflammation, foreign bodies, or other abnormalities were seen. There is a small pre-existing scratch on the external ear flap.- CV: Auscultation of the chest was clear with no abnormalities detected.- Oral Cavity: Teeth were examined and the owner was advised to continue brushing as mild tartar , but really quite good..- Integument: A small scratch was noted on the inside of ear flap.- Abdomen/GI: Abdominal palpation was unremarkable. ASSESSMENT:- Mild ear irritation of unknown aetiology. No evidence of otitis externa or foreign body on examination. The history of rolling in the grass may be relevant. PLAN:- Diagnostic/Treatment Plan: A single dose of a cortisone-based ear drop PMP was instilled into the affected ear to reduce any potential itchiness or inflammation. No further long-term treatment is indicated at this stage.- Recommendations: The owner was advised to monitor the situation and to leave the ear alone to allow the medication to work. A follow-up was recommended if the signs do not resolve. Continue with regular tooth brushing.    Vital Signs