C09997756 / invoice 10000

Hx:
- Presenting problem: Recheck ear infection. Lip lesion resolved. 
 - Now not wanting to go for walks. Will get to end of driveway and sit down and not move

- Eating: Normally
- Drinking: Normally
- Urinating: Normally
- Defecating: Normally

- Any V+/ D+/ coughing/sneezing - sneezing more often
- Current parasite prevention: UTD
- Vaccination status? UTD 
- Any current medication? 40mg fluoxetine SID PO. Traz if needed but didn't find it helped with car trips so stopped using
- Any other concerns None

PE: 
Mentation: BAR
Eyes: NAD
Ears: Mild brown cerumen both ears, no redness
Nose: NAD
Mouth: ds 0/4, MM pink, CRT <2
Heart: HR 120bpm, regular, no murmur, pulses wnl
Lungs: NAD
Abdominal examination: NAD
Skin and coat: NAD
LN: NAD
Temp: Not taken
BCS 6 /9
 MCS A /D

Ortho exam: 
- RFL NAD
- LFL NAD
- RHL NAD
- LHL NAD
- Neck NAD
- Spine NAD

Assessment:
Ear cyto: occ yeast both ears

Walking- could be from stress. Poss try traz 

Treatment:
1.5ml BOVA dex/ket/enro each ear

Plan: 
Monitor ears, recheck if concerned
Trial 100mg-150mg traz 90 minutes prior to walk and see if helps reduce any possible anxiety from walking. Otherwise can take some treats (take kibble out of her meals and take as treats) and see if can encourage her to move with food.