C10007914 / invoice 10000

Presented for -  itchy bum and AG's
poo's normal no D recent and eating well.

Current medications: nill
Parasite control: UTD

Mentation: BAR, wriggly happy dog
EDUF: nad
Diet: hypoallergenic
MM: pink moist
CRT: < 2sec
DS: 0/4
Skin tent: < 1sec
LN: wnl
Ears: clean
Eyes: clear
Thyroid: nad
HR:  100 reg
Chest Auscultation: normal bronchovesicular
Abdo Palpation: soft
BCS5 /9
Temp: np
Rectal Exam:  both AG's mod full easily expressed, cream brown liquid
Skin: anus red slight inflamed
Joints/Gait: ambulating well
Urogenital: nad
Vaccination status:
 
Problem list: 
1) AG's impaction
2) anal pruritis
DDx:

Treatment in clinic: AG's expressed
neocort applied to external anus

Plan: neocort bid anus
O monitor for scooting- re-check AG's required if continues

Communication: as above

Presented for vaccination
generally going well
good response to neptra but ears have just started looking red again
not itchy - o elects no cytopoint today

Current medications:
Parasite control: interceptor

Mentation: bright, alert.  Mostly very good with some boisterous behaviour -able to examine ears and administer intra-nasal with o gently offering treats
EDUF:  nad
Diet: 
MM:  pink
CRT:  imm
DS: 1/4
LN:  nad
Ears:  right ear is red esp external pinna.  LEFT ear has minor discharge with TM still visible
Eyes:  nad
HR:  100
Chest Auscultation:  soft, relaxed
Abdo Palpation: nad 
BCS: 5/9
Temp:  not assessed
Rectal Exam:   nad externally
Skin:  nad
Joints/Gait:  gait normal.  Not very co-operative for limb manipulation but no obvious issues
Urogenital: nad

Problem list:  low grade otitis
Plan: neptra left ear. start elocon right ear - use for 5 days then at the next weekend start maintenance both ears

Communication:

Vaccine Batch numbers:
Nobivac KC: 2526209

Hx: left ear bothering her again. EDUF, no meds. Has had many ear infections. Can get drops in but difficult. 

Examine: very BAR, MM pink, right ear wnl, mild erythema around entrance to ear canal only. Left ear - very inflamed, sore, moist, minimal discharge. No further exam as quite boisterous. 

Plan: O's declined cytology today and very keen for Neptra option. Recheck in 2 wks then if infection resolved, commence Elocon lotion regime. 
Short course Pred also.