C09991157 / invoice 10000

Reason: Sr12 - Wants To See Kei KLGAP ONLY HISTORYFirst clinical signs - N/a Summary -  had PuPD episode after starting pred but now settling downDiagnosis -  clear from the ear infection but start on cortavcance with antifungal for preventionTreatment - cortavance. Sr 12 inj--- 05/03/2026 14:38:30 NQ:Worming - Skipped on 11/06/2025Verified: NoSubjective:Diet: Recent changes to diet: nil #Preventative healthcare:Vacc: vaccination due AugustHWP: IW: Flea/tick: HISTORY:O's presenting complaint/s: - Previous ear infection treated with steroid medication in January- Ear infection cleared up after treatment- Patient was drinking excessively after medication but now drinking normally- Eating normallyAppetite: NormalThirst: NormalVomiting: NilDiarrhoea: NilAccess to chemicals or toxins: Nil knownAccess to rodenticides: Nil knownCurrent medications: NilPrevious medical history: - Previous ear infection treated with steroid medication in January- Thin coat areas prone to ear infectionsExamine:PHYSICAL EXAMINATION:Mentation: alert and responsiveEYES: NAD - clear, no noted dischargeEARS: NAD - clear, no discharge, odour, erythemaNOSE: NAD - clear, no discharge, symmetrical, no lesionsORAL: NAD - normal pink and moist mm, normal CRT, healthy teeth & gumsCARDIOVASCULAR - NAD - no murmur or arrhythmia auscultated, pulse pressures normal and synchronousRESPIRATORY: NAD - thoracic auscultation clear sounds bilaterally, respiratory effort normalABDOMINAL: NAD - soft pliable, no detectable pain or palpable abnormalitiesNEURO: NAD - neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMUSCULOSKELETAL: NAD - ambulating with normal gait & posture, no pain on palpation of joints, appropriate ROMRECTAL: not performedREPRODUCTIVE: externally normalINTEGUMENT: NAD - clear coat and skinLYMPH NODES: NAD - peripheral nodes palpate normalAssessment:Problem List:- History of recurrent ear infections- Predisposition to ear infections due to thin coat areasLaboratory:- Ear sample examined under microscope - no infection detectedTreatment:- Synovan ear cleaning solution with antifungal medication dispensedPlan:- Use Synovan ear cleaner twice weekly (Monday and Thursday) as preventative measure- Monitor for signs of ear infection recurrence- Return if any concerns with earsHISTORY:Examine:PHYSICAL EXAMINATION: Mentation: alert and responsiveEYES: NAD - clear, no noted discharge #EARS: NAD - clear, no discharge, odour, erythema#NOSE: NAD - clear, no discharge, symmetrical, no lesions #ORAL: NAD - normal pink and moist mm, normal CRT, healthy teeth & gums#CARDIOVASCULAR - NAD - no murmur or arrhythmia auscultated, pulse pressures normal and synchronous#RESPIRATORY: NAD - thoracic auscultation clear sounds bilaterally, respiratory effort normal#ABDOMINAL: NAD - soft pliable, no detectable pain or palpable abnormalities#NEURO: NAD - neurologically no significant findings, no cranial nerve or proprioceptive deficits/gait#MUSCULOSKELETAL: NAD - ambulating with normal gait & posture, no pain on palpation of joints, appropriate ROM#RECTAL: not performed#REPRODUCTIVE: externally normal #INTEGUMENT: NAD - clear coat and skin #LYMPH NODES: NAD - peripheral nodes palpate normal #Assessment:Plan:    Vital Signs