C09987431 / invoice 10000

03/03/2026 Primary Presenting Complaint - anal glands, nails, allergy vaccination
Other Complaint - problem w/ one of her teeth
         Loyalty Reward Program - Y/N
History - partner tried to express a/g came out yellow/pussy (a lot came out but thinks more still in there)
         Last Normal - still bright happy well within herself 
         Frequency   - scratches alot pvas 6 
         Last Ate       - this morning 
         Medicine Hx  - just allergy inj
         Vacc Current - yes
         Worming Hx  - due
         Heartworm    - due
         Microchip       -  Y / N    -  scanned - ok?

Examination -
         Attitude - BAR very friendly sweet dog 
         Body Score -    6/10
         Temperature - not taken 
         Heart -  120 HR. Murmur - none heard 
         RR - 32
         Dental - Score(0-4)=  1  .Comment very mild disease. 309 slab fractured 6months ago moderate tartar build up 
         CRT - immediate
         Eyes - some periorbital alopecia O says they are often very gooey in the morning 
         Ears - clean and discharge free
         Abd Palpation - Unremarkable
         Gastrointestinal -  No Sig Findings
         Urogenital -  No Sig Findings
         Skin - always had issues with itchy skin mostly scratches flanks, collar, ears 
         Musculoskeletal -  No Sig Findings
         Neurological -  No Sig Findings
         Lymphatic - No Sig Findings
         Other key findings = 

Assessment - healthy dog 
Problem List - allergic skin disease, fractured 309 possible pulp exposure 
DDx                 - 
Discussed      - cytopoint normally controls scratching really well so o happy to continue with that. was told by other vet a few months ago that the tooth will only be an issue if she begins to have troubles chewing. advised that if there is pulp exposure the tooth needs to be removed sooner as an open pulp cavity can allow infection to enture the blood stream +/- cause a tooth root abcess and is extreemly painful. 
Treatment Plan - will give estimate for removal of the tooth vs can enquire elsewhere for dental xrays for proper evaluation for if it needs removal 
10mg cytopoint given  
Prescriptions(on-going) -
Next Visit            -  as needed