C10009287 / invoice 10000

REASON: ear RV + behavioral 

Physical: 



Assessment: 


Plan: 
DIscusessed starting fluoxtine - O will think about - can dispense script if decises soon 
Referral behavioural specialit 
Avoid getting "bark removed" 




Reason/concerns: ear RV + behavioral

History:
Not shaking or scratching at head. Finished all ear meds and pred. 
O very distressed about anxiety - dog will bark at anyone coming into house, when kids get home. Both O work from home and dog constantly wants attention, will bark and stress. Only started one year ago when moved house. 
O brought up wanting bark removal surgery. 
EDUD: normal
No V+ or D+

Pre-exisitng Conditions / Medications:
- No pre-exisitng conditions noted at the time of examination
- No medications currently being provided at the time of examination

Examine: 
Mentation: BAR
BCS:                  5         /9   
MM: Pink          
CRT: 1-2 seconds
HR:                  125           beats/min
RR:                pant             breaths/min
Temperature:     not taken         degrees Celsius

Ocular: No abnormalities noted on cursory examination of both eyes.
Oral/Dental stage: Mild gingivitis and calculus observed.
Ears: No abnormalities noted on cursory examination of both ears.
Cardiovascular: No audible murmur or arrhythmia and no difficulty hearing the heart. HR = PR and no evidence of hypoperfusion.
Respiratory: Respiratory rate and effort considered normal for the patient. Normal bronchovesicular sounds. 
Gastrointestinal: No pain on abdominal palpation. No masses or abnormalities palpated.
Integumentary: No significant abnormalities.
Musculoskeletal: Normal gait and strength noted. No evidence of lameness.
Urogenital: No significant abnormalities noted during routine physical examination.
Neurological: No evidence of neurological impairment or altered mentation. Detailed neurological examination not performed today.
Lymph nodes: Within normal limits for submandibular, prescapular and popliteal examination.

Problem List:
Generalized severe anxiety w vocalization causing O distress 

Patient Assessment: 

Diagnostics performed (i.e. bloods, radiographs/ultrasound, ear cytology, urinalysis):
- None performed 

Client Communication & Plan: 
- 

Next check up date: 

Reason: Courtesy phone call 
Nurse: Megan 
History: Ears
     Demeanour: BAR
     Eating/ Drinking: NAD
     Toileting: NAD
     Any concerns: nil 
     
Treatment:
     Medications being given: Dermotic 
     Patient taking meds as prescribed: yes 

Assessment: Seems to be going well. 

Next Appointment: TBA