C09992516 / invoice 10000

Ear Issue
Paws App Details:

Booking Type: Consultation - General / Unwell
Booking Vet: - Any -
Booking Notes: Sore Ear Issue 
Pet Insurance Provider & Policy No (if applicable and not provided): WW22337272

History: 
- started 2 nights ago ear shaking and itching at it, not red but a bit of brown gunk 
- also something on the back of his front right leg 
- eddu normally 

Physical Examination: 
- HR wnl no murmur noted, normal and synchronous pulses 
- RR wnl no crackles or wheezes, no stertor or stridor noted 
- Abdo palpation normal no masses,  pain or hernias noted 
- MM moist pink and CRT <2s
- Grade 0 Dental disease: 
- Ears/Eyes/Nose: mild discharge L ear canal, no erythema in either canal 
- No lymphadenopathy noted 
- Skin and coat: clean no obvious lumps or bumps 
- MSK: no lameness noted in consult, full MSK examination not performed today 
- Temperature: not taken today 
- BCS: 5/9
- BAR no neurological deficits noted 
- Rectal: not performed today 

Diagnsotics: 
cytology ears bilateral: malasezzia ++

Treatment: 
dermotic bid both ears 7 days

Plan: 
recheck in a week 

Teeth / Vaccination / Vaccine
Paws App Details:

Booking Type: Vaccination
Booking Vet: - Any -
Booking Notes: BB/Pi vaccination 
Heart worm Vaccine 
Teeth 
Pet Insurance Provider & Policy No (if applicable and not provided): Everyday Pet Insurance - WW22337272

Due vacc and proheart, been well. EDDU normally, think teeth are a bit brown. STO on phone about t/f/w/hw. thinking he has been on trio monthy, not sure if always utd. elect proheart today, rec HWT in 6m if unsure

Exam; anxious to examine but ok,
HR RR reg, 
gums moist pink crt 2
ears, eyes ok. 
PLN wnl 
healthy coat and skin 
MSK comfortable 
abdo palp NAD 
bcs- bit heavy, could lose few KGs 

small amount plaque on teeth, mainly insides of incisors, no gingivitis, grd 1 plaque vvery mild. could consider s+p at some stage but think can watch for now

Tx;
BBpi injectable
Proheart

ripped nail, limping on it, v uncomfortable
Torn outside lateral toenail left hind- was hianging there, so could just pull it off , is a little bit of nail remaining so have told owners if he is still bothered by it, back Monday and we would have to sedate him and peel all nail off 
he seems fine now so I am hoping this will be fine 
Hoem on noroclav 
trimmed all nails