C09991634 / invoice 10000

Reason: Vaccination KLDiet: Preventative healthcare:Vacc:HWP:IW:Flea/tick:HISTORY:O's presenting complaint(s): Examine:PHYSICAL EXAMINATION: BCS: ## / 9MCS: normal muscle mass #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:GAP ONLY HISTORYFirst clinical signs - check ears and examinationSummary - mild Otitis and sr12Diagnosis - mild OtitisTreatment - cortavance and sr12Verified: NoSubjective:Diet: Recent changes to diet: nilPreventative healthcare:Vacc: HWP: IW: Flea/tick: Nexgard - up to dateHISTORY:O's presenting complaint/s: Ear infection - long term issue, requesting ear cleaning- Golden retriever, almost 4 years old- History of ear infections approximately 12 months ago- Currently using preventive ear medication (Cortavance) BID weekly when remembered- Some weeks gets BID weekly, other weeks doesn't- No significant ear problems since starting preventive treatment- Scratches occasionally when wearing harness but settles quickly- Regular grooming and bathing at home- Third golden retriever for this familyAppetite: NormalThirst: NormalVomiting: NilDiarrhoea: NilAccess to chemicals or toxins: Nil knownAccess to rodenticides: Nil knownCurrent medications: Cortavance BID weekly as maintenancePrevious medical history: - Hot spot incident in 2001- Couple of ear flare-ups associated with allergies- No significant ongoing health issuesExamine:PHYSICAL EXAMINATION:Mentation: alert and responsiveEYES: NAD - clear, no noted dischargeEARS: Right ear worse than left, some malassezia present on microscopyNOSE: 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:- Bilateral otitis externa with malassezia- Right ear more affected than leftLaboratory:- Ear cytology: malassezia present, nothing very excitingTreatment:Plan:- Resume Cortavance daily for 5 days to boost treatment- Return to BID weekly maintenance dosing- Continue current parasite prevention- Monitor ear condition    Vital Signs    Weight: 40.5;