C09989756 / invoice 30000

Reason for Visit: Shaking head

H:
Been shaking head since given bath at groomers last week.
No other concerns. 
EDDU Normal
No Vomiting / Coughing / Sneezing
UTD on Vacc / Para tx.

E:
BAR - Nice dog. 
BCS 5/9
HR 120 - No murmurs or arrhythmias
Pulses Normokinetic
MM Pink/Moist
CRT <2
RR - Pant - Normal Bronchovesicular Sounds
Abdo palpation - Soft and comfortable.
LNs NAD
Skin NAD
Ears Mild errythema L ear, R ear looks normal externally. No discharge from either ear.
Eyes NAD
Ortho NAD

Otoscopic examination: L ear has mild discharge further down canal. Could visualise TM. R ear minimal discharge / regular wax.

Cytology:
L ear: Yeast + Cocci +
R ear: NAD

A:
Otitis externa of L ear.

P:
Aurizon 0.5ml 8 days in L ear.
RV in 10 days. 

History: 
Here for annual vacc + nail trim. Doing well post dog attack. Is scratching behind ears and on neck occasionally, according to O - but is UTD with monthly parasite control (Nexguard). EDUD normal. No v+/d+, no sneezing, coughing. NOC

Examination:
BEHAVIOUR: BAR, Lovely girl, pretty wriggly though.
EYES, NOSE: NAD 
EARS: Both Ear pinnae and outer canals look pink, healthy, no smell or signs of ear infection. Skin behind ear and on neck also healthy, pink, no redness/inflammation/hair loss.
ORAL: dental grade /4, gums & MMs pink and moist, CRT <2s, NAD
CVS: HR 140, no arrhythmias or murmurs, pulses normokinetic
RESP: RR 25, lung sounds clear
ABDO: soft and comfortable, NAD
LYMPH NODES: NAD
MSK, ORTHO: NAD
NEURO: NAD, full examination not performed
INTEG: coat bright and shiny, NAD
BCS:  4.5/9

Assessment:
Fit to vaccinate

Treatment:
Gave Nobivac BB/Pi (C2) SQ - signed O Vacc cert/book
Trimmed nails

Plan/Next Visit:
- Advised O to keep eye on scratching - no current signs of skin infection/parasites or allergic dermatitis, but if worsens, will need to look into possibility of allergies.
- Next BB/Pi due 06/26
- Next DHP due 06/26
O to call if any concerns.