C10010273 / invoice 10000

HISTORY
Presenting for: check eye
L cherry eye started yesterday
Has happened a few times before but always goes away quickly, overnight
Seems slightly sore
No health issues recently 
Nil meds

EXAM
BAR, friendly
Weight 10.35kg
BCS 6/9
HR 120, no m/a noted
RR NAD
Temp nt
Abdomen soft
MM PM<2s
L eye:
R eye NAD

ASSESSMENT

PLAN

COMMUNICATION

HISTORY: Presenting for sore paw 
RV = paws at yours
one of paws o thinks had a nick in it and ever since then she's been licking at her paw and now its red. 
going into kennel next week so O worried about infection 
otherwise well 
eddu normal no cvds

Pre-existing conditions/ current medications: none

EXAMINATION:
BAR, BCS 6/9, T nt
Eyes: nad
Ears: nad
Oral: pd 0/4
MM: pm <2s
HR: 120
RR: panting, no crackles or wheezes
Abdomen: soft and nonpainful
LN: nad
Integ:
LHL between digit 3 and 4 the skin is very erythematous and ulcerated, the skin underneath this paw as well is erythematous and irritated. tape prep --> mostly cellular debris and occasional cocci in pairs

ASSESSMENT:
LHL between digit 3 and 4 ulcerated skin ddx. trauma (self induced via licking)

TREATMENT/ TREATMENT PLAN:
recco econe- O says has at home vs wound gard to prevent licking
cephalexin 25mg/kg po bid till finished
pred 0.5mg/kg po sid for 5 days then eod till finished due to licking 
chlorhex cleans bid 

COMMUNICATION:
review in 2 weeks INI
disc watch for side effects of medication eg hunger thirst v+ or d+

SUBJECTIVE: 
jumped off bed and got stuck, NWL to LFL. Prior to this well

OBJECTIVE: 
BAR
TPR WNL, NAD on ausc
MM pink and moist CRT<2sec, 
Eyes/Ears/Integument WNL 
Comfortable on abdo palpation 
1/5 lameness noted to LFL, good ROM of all joints

ASSESSMENT: strain to LFL

DIAGNOSTIC PLAN:

THERAPY: 
To start oral meloxicam SID for 2 days and REST

CLIENT COMMUNICATION: 
INI/worsens to return