C10008139 / invoice 10000

07/03/2026 Reason: C5 vaccination 

Owner reports:
- shaking and scratching ears 
- energy levels good 
- EDDU wnl 
- no v+ d+ coughing sneezing 
- usually eats grass or random things at the park and gets d+ but resolves in a day 
- sleeping well
- Diet: Blackhawk puppy 
- UTD with Simparica Trio 
- no current meds 
- no supplements 
- check desexing incision site 
- hard to clean teeth or ears 
- no other concerns 

Physical Examination: 
BAR anxious but lovely will eat duck and chicken 
BCS 5-6/9 
HR 136 no murmur or arrthymia
RR panting clear lung sounds 
Pink mm crt <2sec 
DS 0.5/4 very mild tartar 
Incision site healed well (from desexing)
All palpable lymph nodes normal 
Abdominal palpation soft and comfortable 
Eyes normal
Ear cytology - mild yeasts bilaterally no other cells present 
Temp 38.6

Assessment/Client communication:
1. Fit for injection.
2. Has mild yeast infections. Discussed no need for ear cleaning if no clinical signs. Recommended dermotic or osurnia treatment. Owner opted for osurnia as very reactive with ears touched
3. Discussed training for nail clipping, ears touching, walking down ramp from couch to prevent injury.
4. Discussed keeping weight lean and more endurance walks, reduce sprinting and quick turns to prevent risks of IVDD etc. Need training on ramps, very food motivated can help 
5. Recommended brushing teeth positively but if not possible to book in GA dental procedure. 
6. Recommended intranasal KC vaccination as VERY needle phobic and recommended previsit meds for relaxation as only young. Owners will pick up some next time. 

Treatment:
1. Duramune C3 vaccination given s/c 
2. Canigen KC vaccination given s/c 
Note: VERY needle phobic 

Plan:
1. Owner to pick up previsit meds prior to future vet appointments: Gabapentin 100mg 2 tablets PO night before. Gabapentin 100mg 2 tablets WITH Trazodone 50mg 1 capsule 2 hours prior to vet visit.
2. Owner to apply Osurnia Ear Gel Apply 1 pipette in each ear and massage today. Apply 1 pipette in each ear on 14 March. Recheck 1 week from the last application.
3. Due for KC vaccination in a year 7 March 2027. (STRONGLY RECOMMEND Intranasal if possible, very needle phobic) 
4. Due for Duramune C3 vaccination in three years 7 March 2029. 
5. Owner to transition to adult diet over 1-2 weeks gradually.