C09994791 / invoice 10000

tuesday night getting progressively worsehacking and cough apetite - eating fairly regular HISTORYPrimary reason consult: Sneezing and coughingConcerns: NoneHistorical conditions: Previous allergy episodesVacc due: UTD with core vaccines, Heartworm injection currentWorming/ flea/tick: NexGardCurrent medications: NoMentation at home: BAREDDU: eating & drinking normal urination and defection normal No vomitingDiet: Skin: no pruritis, no lesionsLumps: Mobility: no pain, no lameness, no ataxiaRisk Factors: Dog parks (not daily)PHYSICAL EXAMCondition: BCS= /9, healthy bodyweightMentation: BARMobility: ambulating well, no lameness or ataxia observed, no abnormalities on palpation of joints and musculatureHR/PR: 100 clear on auscultation bilaterally, regular and strong pulseLungs/RR: panting lungs clear on auscultation bilaterally, normal breathing sounds and effortTemp: 38.7 deg CMM: Teeth: dental tartar buildupEyes: normal appearance of eye and eyelids, normal pupillary responsesEars: normal appearance of pinna and external ear canal, no malodourSkin/Coat: healthy skin and coat without redness, lesions, excessive hair loss or lumpsLnn: no enlargement palpable externallyAbdom palp: Other problems found: PROBLEM LIST- Sneezing episodes daily- Occasional coughing- Dental tartar buildupDIFFERENTIALS Allergies most likely, kennel cough less likely given vaccination status and lack of feverTESTS PLAN- Short course anti-inflammatory dose steroids- Avoid dog parks while symptomatic- Monitor response to treatment- Recheck if symptoms persist or worsenCLIENT COMMUNICATION- Steroids will increase water and food intake temporarily- Give whole tablet daily for 3 days, then half tablet daily for 5 days, then half tablet every second day until finished- Avoid dog parks while sneezing- Return if not responding to treatment or symptoms worsen- Dental care recommended - teeth brushing- Can give NexGard Spectra at home (will double up on heartworm component but safe)- Expected improvement within 5 daysTREATMENT- Prednisolone tablets dispensed with tapering dose schedule    Vital Signs    

HISTORYPrimary reason consult: vomitingConcerns: watery vomit this morning, dry heaving afterwardsVacc due: UTDWorming/ flea/ tick: UTDCurrent medications: noneMentation: little more quiet than usualEDDU: off his food this morning, not drinking as muchDiet: dryfood in the morning, evening wetfood/mince/veggiesSkin: no pruritus, no lesions, no lumpsMobility: no pain, no lameness, no ataxia, good energy for walks stillPHYSICAL EXAMCondition: healthy bodyweightMentation: bright, alert and responsiveMobility: ambulating well, no lameness or ataxia observed, no abnormalities on palpation of joints and musculatureHR: clear on auscultation bilaterally, regular and strong pulseRR: lungs clear on auscultation bilaterally, normal breathing sounds and effortTemp: 38.0MM: pink, CRT<2secTeeth: appropriate bite, clean, no gingivitisEyes: normal appearance of eye and eyelids, normal pupillary responseEars: normal appearance of pinna and external ear canal, no malodourSkin/Coat: healthy skin and coat without redness, lesions, excessive hair loss or lumpsLnn: no enlargement palpable externallyAbdom palp: soft and comfortable, no masses or organomegaly notedPROBLEM LIST- vomiting/retchingDIFFERENTIALS- gastro enteritis, dietary indiscretion, FB, infection vs metabolicTESTS- PLAN- prevomax + monitoringCLIENT COMMUNICATION- prevomax works for 24 hrs, if continues to vomit throughout afternoon, revisit. If not better in a few days, revisit. Suspect dietary indiscretion or catching bugs (he hunts cockroaches a lot)TREATMENTprevomax 0.5ml SC    Vital Signs    Weight: 5.2;       

Appointment Reason: Eye infection / Eyes / Discharge, Appointment Notes: Paws App Details:Booking Type: Dog VaccinationBooking Notes: Eye infection Eyes Discharge Owner Name: Kayla MckenzieOwner Email: kayla.mckenzie@hotmail.comOwner Mobile Number: 0405732927Pet Name: ArloPet Species: DogWeb BookingClient name: MckenzieContact number: 0405732927Email address: kayla.mckenzie@hotmail.comPatient name: ArloHistory:O noticed green ocular discharge in both eyes since friday nightEDDU normallyNo V/D+Not on any medsExamination:BCS 4/9 BARHR: 120, no murmursRR: clear, norm resp effortmm pk, CRT <2sDental grade 0-1Eyes: bilateral conjunctivis and green ocular discharge. No blepharospasm. FL neg both eyesEars: NADLNs WNLAbdo soft and comfortableInteg: NADAssessment:Bilateral conjunctivitisPlan:Choropt 2-3x a day both eyes 7 daysDiscussed dental dx prevention    Vital Signs    Weight: 5.2;