C10004836 / invoice 10000

Reason: EarsHistory:Scratching ears and flapping getting worse over the past 6 weeks or so Well otherwise no issues, EDDU normal, no v+/d+Ocasional paw chewing but nothing significant, similar time period Has cleaned out with cotton bud, a bit dark brown discharge No otitis previouslyRecurring dental procedures neededDiet: kibble + wet supermarket ballsFTW = Nexgard spectra + paraguard UTD Vaccinations: kc overdue by a year, O not keen to do for now; left reminder may do at dental procedureCurrent medications: noneExamination:Temperament: lovely girlCardiovascular: HR: 90, no murmurs or arrhythmias, femoral pulses strong & synchronous, oral mucous membranes pink & moist, CRT 1 second.Respiratory: RR: panting; Eupnoeic, no crackles/wheezes on auscultation. Oral exam: . Dental grade 2 marked tartar upper molars with some gingivitis - front of mouth low gradeEyes: WNL – No pain, discharge, erythema, or opacity. Ears: Mild dark discharge deep in canals R>L, mildly itchy on palpation and swabbing. TMs intact bilaterally.Nose: WNL – No discharge or erythema. Patent nares with no stenosis Peripheral lymph nodes: WNL – Palpated with no obvious abnormalities Integument: Full coat, normal skin tent. Abdominal palpation:  Palpated with no obvious pain, tension, or abnormal structures.Gait: Readily ambulatory, no ataxia or lameness.Musculoskeletal: WNL  - Able to right, rise and ambulate without difficulty. BCS 5/9.Neurological: Mentation & responsiveness appropriate, full exam not done.Urogenital: WNL on external examination. Rectal exam: Not performed.Cytology: yeast + bilaterallyAssessment: Otitis externa, likely mildly atopic dog Plan:Dermotic 1ml bilaterally BID 10 daysRecheck 14d - only essential INI at this stage, mild infection should resolve wellDental warranted, to email estimate with prep bloods and radsClient communication: Chat re atopy - didnt go too in depth today since such mild signs but if recurs may need a further chat    Vital Signs    Weight: 9.7;