C10025319 / invoice 10000

Reason: ears

History: 
 - shaking head for about 2d and ears feel hot
 - not had this before
 - licks at his feet every now and then
 
Pre-existing conditions: allergic to grasses etc?
Current medications: intermittently gives antihist (telfast) Last had one 2d ago

Appetite: normal
Drinking: normal
Urination: normal
Defecation: normal
D+, V+, coughing? none

PE
Mentation:BAR, , 
BCS: 3./5
MM: pink and moist
CRT: 1-2s
HR: 130 bpm, no murmurs or arrhythmias detected
PR: normodynamic and synchronous
RR: normal effort and no abnormal lung sounds
Temp: not taken
Ears: 
 - ears actually look pretty good on scoping
 - mld erythema of canals R>L
 - no obv fb (althoug difficult to keep him still) and no obv issue with the TMs
Oral/dental stage: 0/4 
LN: submandibular, prescapular and popliteal are small, symmetrical, non-painful and WNL on examination
Abdo: no pain on abdominal palpation, no organomegaly or masses palpated
Integument: normal skin turgor, nsf
Urogenital: no significant abnormalities 
MSK: ambulatory, normal gait and strength noted. No evidence of lameness
Rectal exam: not performed
Neuro exam: nsf on cursory examination

Assessment:
Mild Pruritic ears of unknown (but suspected allergic) origin

Discussion: 
not happy giving topical meds etc at the moment as minimal changes and no discharge etc
Treatment:
0.75ml dexason SC
can cont antihist (given our handout to check doses at home)
Plan
ini the recheck

follow up SMS sent - no rads booked yet KJ

Reason: Pain
History:
O noticed sometimes he is sore and slow to rise on back legs
Warms up
No obvious limping just seems a bit stiff and slow
Ongoing medical conditions - None
Current medications - None
UTD deworming/ectoparasite – Y

Examine:
Mentation: BAR, friendly and very bouncy
BCS: 5/9
MM: pink/moist    CRT: <2s
HR: 82                RR: pant ++
Temp: Not performed
PLN: Submandibular, popliteal and prescap wnl
Eyes: OU WNL, no squinting or discharge, PLR symmetric
Oral: mild dental grade, G1/C1
Ears: nsf
Cardio: reg no murmur
Resp: nsf, no increase in effort or sounds
GIT: no pain on palpation, no obvious mass effect, no fluid wave
Integ: nsf
MSK: mild restriction to L hip
 - yelping on R hip extension, unable to get full extension
Urogenital: nsf, no discharge
Rectal: Not performed 

Problem List:
1/ Back R hip extension, mild on LHS
Working ddx: hip dysplasia, pain
A: needs hip xrays. Will also do stifles at the same time
P: X-rays needed, O aware, est sent

Follow-up:
Book in for rads