C09996369 / invoice 10000

CoughingHISTORY:Coughing for the last few daysGets worse when goes for walks or gets excited Sounds like she has a hair ball stuck in her throat. At doggy daycare last Monday and regularly goes to dog parks. Due to go to Kennels tomorroeEXAMINATION:Lovely dog MM: Pink and moist CRT < 2 secondDemeanour: BARHydration: Euhydrated Cardiovascular: Dual heart sounds auscultated, no murmur or arrhythmia detected, SSFPRespiratory: Normal bronchovesicular sounds bilaterally, normal resp rate and effort. Very reactive to tracheal pinch. Dry hacking cough with terminal retch. Bringing up small amount of white sputum. Neurological: Appropriate & normal mentation, gait and postureMusculoskeletal exam: Good BCS and normal ambulation Gastrointestinal: Comfortable on abdominal palpation Genito /Urinary: Bladder palpates WNLIntegument: Good coat condition, no ectoparasites visualised Eyes: Symmetrical, no ocular discharge or blepharospasmEars: Normal, no auricular discharge bilaterallyMouth: Dental grade 1/4Lymph Nodes: Submandibular, prescapular and popliteal palpate normallyPROBLEM LIST:Coughing for last 2-3 days ASSESSMENT:Suspect infectious tracheobronchitits (KC)TREATMENT:Doxycycline 150mg BID for 5 daysLincotol syrup 5-10ml q 8-12 hoursPLAN:Recommend to avoid contact with other dogs for next 7 daysAllow her to rest and ensure good hydration is maintained Feed wet food INI or any concerns, recommend recheck .

Scabby wound on RFore, and itchy ears HISTORY:Desexed 12 days ago. Surgery site looks great, but keeps licking her arm where the catheter was placed. Now skin is red and bleeding. Also has been itching her ears - L ear now looks very inflammed and possibly bleeding?EXAMINATION:Lovely dog, but VERY boisterousMM: Pink and moist CRT < 2 secondDemeanour: BARHydration: Euhydrated Cardiovascular: Dual heart sounds auscultated, no murmur or arrhythmia detected, SSFPRespiratory: Normal bronchovesicular sounds bilaterally, normal effortNeurological: Appropriate & normal mentation, gait and postureMusculoskeletal exam: Good BCS and normal ambulation - NAD Gastrointestinal: Comfortable on abdominal palpation Genito /Urinary: Bladder palpates WNLIntegument: focal pyoderma over catheter site on R fore. Skin is ulcerated and crusty, odematous and red. Eyes: Symmetrical, no ocular discharge or blepharospasmEars: L ear feels hot and skin appears dry and scaley. VERY pruritic.  External meatus is very inflammed and contains brownish coloured secretion. R ear looks fine - NAD Mouth: Dental grade 1/4Lymph Nodes: Submandibular, prescapular and popliteal palpate normallyLAB:Ear smear and diff quik stain-> Malasezzia in L ear +++. R ear NAD ASSESSMENT:Pyoderma on R foreOtitis externa - yeast L earTREATMENT:Amoxyclav 500mg BID for 7 daysNeocort BID (owner already has tube at home)Dermotic for ears - 1ml into the L ear BID PLAN:Recommend recheck in 10 days or sooner if any concerns.

In today for post-op check Doing really well. Happy and bright. EDUF all normal No longer on any medsSurgery site looks great. Wound lovely and clean. No sign of inflammation or infection Advised owner to continue to keep quite. No baths or swimming for another 5 days.