C09990078 / invoice 10000

Presenting for: ear issues - groomer noticed a yeasty smell when he was groomed yesterday. O wanted to check. Otherwise fine
ED: fine
UF: fine
V/D: nil

Exam:
Demeanour: BAR
CVS: HR regular, no murmur or arrythmia
Resp: Normal bronchovesicular sounds and effort
GI: Abdomen soft on palpation
MSK: Normal gait, ambulatory
Neuro: Full neuro not performed
Eyes: Clear, reflective
Ears: Pink, no discharge. Otoscopic exam: minimal cerumen and fluff. No inflammation
Nose: Moist, no discharge
Oral: NAD
LNs: Submandibular WNL
BCS: 5/9

Assessment:
Cytology: Yeast ++ in R ear, + in L ear
- Fungal OE

Plan:
- Dispensed Dermotic to apply to both ears twice daily
- Warned O that ear infections may be a recurring issue

Hx; final puppy vaccination
Normal EDUD
No V/D

BAR
HR 120, NAD
Resp NAD
MM pink, <1 sec
Teeth Good
Abdo comfortable
2 testicles in scrotum

Healthy to vaccinate.
C4 administered.
Wormed at home.

Advised owner to desex at 6 months of age.

History: Presented for  vaccination. EDUD normal, going good.
client got the dog 2 weeks back, 
 
Examination: 
Demeanor: BAR
BCS: 5/9
CV: Normal rate, rhythm and sounds, mm pink and moist, CRT <2s, no murmur could be detected
Resp: Normal sounds, respiratory rate and effort- WNL
Oral:   level bite
Abdomen: comfortable to palpate, no mass or pain response on palpation
Peripheral LNs: WNL
MS: Ambulating fine in all four limbs
Skin/Coat: healthy
Eyes/Ears/Nose: NAD


Assessment: Fit to vaccinate.

Rx: C5 given
 booster due in 2 weeks