C09986364 / invoice 10000

Reason: Vaccination
History:  OR going ok with exception of R ear bothering him since the weekend
No toher concerns
EDUF: all fine
V#/ D#/ Coughing?  nil

Current medications: nil

What Preventative health cover is being used and do you need to purchase any today? 
Worming: not utd
Flea control: not utd
Heartworm Prevention: not utd
(TWP discussed: Yes/No)

Examine: 
Mentation: bar
BCS (0-5):      4  
MM:              p,m    CRT: <1
HR:          100         RR: pant >100
Dental Stage: 1-2
Temperature: ne
Gastrointestinal: comfortable, moderate sized belly 
Integumentary & lumps (measurement, location): nsf
Musculoskeletal: nsf

Any additional findings:
L ear mild erythema but no discharge
R ear mild erythema & scant discharge, mild stenosis

Assessment: 
fit to vac
overweight
dental dz - discussed COHAT & home care
adv on PP control

Treatment: 
R ear cleaned with otoflush in cons
elocon 0.5ml sid for 5 d then once weekly

On-going medications required: Y/N (use prescription tab for further supply):

Vaccination given:
Batch number: oral bb 2532515 07/2027 po // dhppi 2532515 07/2027s/c

Annual vaccination needed:cc1 in 12 mth

Reason: Vaccination
History: OR ears might have flared again - other dogs very interested & they seems a bit smelly
also itchy
Saw good response to cytopoiint last time
Has continued to use otoflush weekly
also overdue vaccs - going into kennels in July

EDUF:  all fine
V#/ D#/ Coughing?  nil

Current medications: nil

What Preventative health cover is being used and do you need to purchase any today? 
Worming: utd
Flea control: utd
Heartworm Prevention: utd
(TWP discussed: Yes/No) Y

Examine: 
Mentation: bar
BCS (0-5): 4       
MM:  p,m     CRT: <1
HR:  120    RR:  20
Dental Stage: 1
Temperature: ne
Gastrointestinal: comfortable 
Integumentary & lumps (measurement, location): moderate interdigital erythema
Musculoskeletal: nsf

Any additional findings:
Ears - L>R, erythema with discharge & stenosis, chronic changes to L pinnae
cytology - cocci & malassezia, keratinocytes

Assessment: 
OE
pododermatitis
puritus
overweight
dental dz

Discussed allergic skin dz - O believes environmental - consider - more freq cytopoints to control itch, medicated shampoo to control 2ndry infection, elocon for ear maintenance, rv at end of demrotic course to ensure infection resolved

Treatment: 
cytopoint 20mg 773260 07/2026
dermotic bid both ears
otoflush

Vaccination given: protech c3 4964018B 26.03.2026 // Bs III 5267024B 25.09.2026
Batch number:
Annual vaccination needed: cc1 in 12 mth, c5 in 3 yr

adv recheck ears in 10d - consider elocon ongoing

Reason: pruritus 
History: shaking head, itching everywhere, licking at feet - has been doing for few weeks but getting worse
EDUF: all normal, no concerns. Drinks and urinates a lot, has always done 
V/D: none 

Current medications: none 

Vaccination: overdue 
Worming: UTD - TWP 
Flea control: UTD
Heartworm Prevention: UTD

Examine: 
Mentation: BAR
Body condition score: 3.5/5
MM: PM               
CRT: 1-2s
HR: 120              
RR: panting
LN: WNL
Temperature: ne

Ocular: NAD
Oral/Dental stage: 1/4 - mild calc, no gingivitis 
Cardiovascular: no m/a - difficult to auscultate due to panting even with holding mouth shut 
Respiratory: no abnormal lung sounds 
Gastrointestinal: tense, tight, large abdomen 
Integumentary & lumps (measurement, location): thinning hair esp ventrum, ventral hyperpigmentation, pot-belly appearance. Very mild ventral interdigital erythema front feet 

Ears:
L ear: small amount brown discharge on swab, TM intact. Cytology: NAD
R ear: mild erythema, moderate brown discharge, could not see TM. Cytology: malassezia 15-20/hpf

Assessment: 
Unilateral malassezia OE R ear. DDx: underlying allergy, could not r/o FB, poss contributing endocrinopathy. Discussed ear flush prior to medicating, discussed v rough cost, O opted to trial medication prior
General pruritus without significant superficial dermatitis - rec cytopoint
Cushioning appearance, possible PU/PD - rec LDDST and GHP, O initially interested but declined for now due to cost 
Vaccine overdue 

Treatment: 
Cytopoint 20mg 748067 exp: 02/2026
Dermotic 0.5ml BID 10 days R ear - discussed risk ototoxicity 
Otoflush 0.5ml both ears 

Plan: 
rv 10 days for cytology, rv sooner for ear flush if getting worse, O to monitor for head tilt