C10028462 / invoice 10000

Reason/concerns:  

History:
- 
- Diet: 
- EDUD: normal
- No V+ or D+
- Prophy: 
- no other concerns at home 

Pre-exisitng Conditions / Medications: Nil 


Examine: 
Mentation: BAR
BCS:                           /9   
MM: Pink          
CRT: 1-2 seconds
HR:                             beats/min
RR:                             breaths/min
Temperature:              degrees Celsius

Ocular: No abnormalities noted on cursory examination of both eyes.
Oral/Dental stage: x  gingivitis and calculus observed. Gx/4 dental disease. 
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.
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 mandibular, prescapular and popliteal examination.

Problem List:

Patient Assessment: acute unilateral OE. 

Diagnostics performed (i.e. bloods, radiographs/ultrasound, ear cytology, urinalysis):
- Cytology: 
R; wnl 
L;  yeast +++, cocci +

Treatment with medication dose rates (if any):
- Dermotic 
- Otoflush 
- Pred 

Client Communication & Plan: 
- RV in 10d do not apply ear meds day of 
- Apply dermotic 30m after otoflush 
-

On-going medications required: Y/N (use prescription tab for further supply):

Next check up date:

Reason: Post op check 
Consult Nurse: Jas 
History: Dental Extractions performed on 12/02/26
     EDUF: yes 
     V#/D#/Coughing? no 

Examine:

Post Operative:
     Surgery Site: All extraction sites have healed, looking really well. no signs of infection or breakdown. 
     Sutures:  Dissolvable 
     Bandage: N/A 

Assessment: Going well at home, owner has no concerns. Eating well. Can continue soft food for the next week or so and transition to normal diet. 

Treatment: Ecollar can be removed 

Next Appointment: As required. Reminder set in 6 months for re check. 

Reason: Courtesy phone call 
Nurse: CB
History: extractions
    

Treatment:
     Medications being given: Meloxicam 0.78ml SID after 5pm q7d start 13/2 / Clav 250mg 1 tab BID 7d start 12/2
     Patient taking meds as prescribed? 

ttconalm - CB

Good sleep last night, very tired.
Hasn't had much to drink.
Had a little bit of dinner last night and little bit of breakfast this morning.
No V+ or D+.