C10000571 / invoice 10000

PRESENTING/OWNERS CHIEF COMPLAINT/REASON FOR VISIT
Koda presented for a routine health check.

Consult Nurse
Angie

History
EDDU: Abnormal  
Vomiting/Diarrhea: No V+ or D+  
Diet: My Dog brand (biscuits and cans). Treats include dental chews and strips.  
Vaccinations:  C5 Jul 26
Preventatives:
-   Worming: Simparica Trio monthly
-   Heartworm: Simparica Trio monthly.
-   Flea & Tick: Simparica Trio monthly.
Current Age: 5 years old  
Current Medications: None  
Behaviour Concerns: Snores very loudly and sleeps a lot.  
History: Koda was last seen for her desexing procedure last year. The owner reports she has been recently scratching at her ears. She has had a significant weight gain since being desexed, increasing from 8.9 kg to 15 kg. She had an ear infection the week after her desexing.

Physical Exam
General Appearance: BAR;  
Behaviour:  friendly
Vitals: HR: 140 bpm; RR: 40 bpm; T: 38.7 ¡C; MMC: ; CRT:  
Hydration: normal  
BCS: 9/9  
EENT: eyes clear, no evidence of conjunctivitis, no discharge or blephrospasm; Significant earwax noted deep in both ear canals; no nasal discharge; Dental disease is present, including gingivitis, a loose tooth, and another several that are suspected to require extraction.  
Cardiac: normal rate and rhythm, no murmurs on auscultation  
Resp: normal rate, normal clear sounds auscultated in all lung fields, mild inspiratory stertor  
Abdo: comfortable on abdominal palpation, no palpable abnormalities  
Urogenital:  speyed
Integument: no external parasites noted; no erythema or pruritis. The owner reports pruritus affecting the ears.  
Neuro: proprioception NAD; NSF  
Musculoskeletal: ROM in all joints NAD; no abnormalities on palpation  
Lymph Nodes: Peripheral LN's WNL

Client Communication from Consult Nurse
Nurse Angie introduced herself and confirmed the reason for the visit was a routine health check, noting that Koda was last seen for her desexing procedure.

Client Communication with Vet
Dr. Danielle discussed the following with the owner:
-   Weight Management: Koda's significant weight gain from 8.9 kg to 15 kg since her desexing was discussed. It was explained that a spayed dog's metabolism can slow by up to 20%, contributing to weight gain. A weight loss plan was strongly recommended with a target weight of 10 kg. The owner was advised to feed approximately 350 calories per day, which would require calculating the calories in her current diet ('My Dog' brand and treats) and gradually reducing the quantity. It was advised not to reduce the volume by more than 20% at a time to avoid nutrient deficiencies. It was also mentioned that weight loss could help reduce her loud snoring.
-   Dental Health: The presence of dental disease was demonstrated to the owner, including gingivitis and a loose tooth. Another tooth was also identified as likely needing removal. A full dental procedure was recommended, which would include a scale and polish, full-mouth dental X-rays, and extractions. The owner was advised that a treatment plan estimate would be provided and that they would be called during the procedure if any additional extractions were deemed necessary.
-   Ear Health: A significant amount of earwax was noted deep in both of Koda's ears. Given the history of scratching, an ear cytology was recommended to check for an underlying infection, such as yeast. It was explained that if an infection is found, a course of ear drops would be prescribed for one week, with a recheck to follow to ensure resolution.

Laboratory/Imaging
Abnormalities: Ear cytology was recommended to investigate for yeast/bacterial overgrowth due to excess wax and a history of scratching.  
Veterinarian's Interpretation/Summary: Yeast 2+ AU

Assessment/Problem list
-   Obesity
-   Dental Disease (with teeth requiring extraction)
-   Otitis Externa (yeast)
-   Brachycephalic Obstructive Airway Syndrome (suspected, exacerbated by obesity)

Treatment
Medications:  PMP 0.5 ml AU BID x 7d

Plan
-   Weight Management: The owner is to calculate Koda's current caloric intake and gradually reduce food quantity to aim for a target of approximately 350 calories per day. The goal is weight loss towards a target of 10 kg.
-   Dental Procedure: Schedule Koda for a dental scale and polish, dental X-rays, and necessary extractions. A treatment plan estimate will be provided to the owner.
-   Ear Health: Proceed with an ear cytology to investigate for infection. If results are positive, begin treatment with appropriate ear drops and schedule a recheck in 1 week.
-   Next Visit: A general health check is recommended in 6 months.

Internal treatment plan Comms
Please prepare a treatment plan estimate for a dental procedure. Include costs for anaesthesia, IV fluids, a scale and polish, full-mouth dental X-rays, and surgical extraction time for at least 2 teeth.

Follow up notes
A team member is to contact the owner to discuss scheduling the dental procedure and to follow up on the ear cytology results.  
Follow up phone call for: 3 days