C10032568 / invoice 10000

Reason: Ears: Client Present:Nurse:Healthy Pets Wellness Testing: Done Yes / NoVaccination Type:Intestinal worming:current Heartworm Prevention:^^Flea Prevention:^^Tick control:^^Microchip:Insurance and Healthy Pets Plus:Behaviour concerns:Current medications:Current Diet:Type of Shampoo/Frequency:Toileting:__________________________________________________________________________History: Since yesterday he has been shaking his head excessively - was shaking all through the night and whining in discomfort No previous issues with ears or itchy skinEating and drinking wellNo vomiting or diarrhoeaExamination: Mental State: normalEyes: symmetrical, no redness or opacities presentEars: both canals erythemic and mild amount of dark brown discharge present, excoriations end of pinnas. Pruritic and painful, shaking head excessively in consultTeeth: Level 0Mucous membranes: pink External Lymph nodes: normalHeart sounds: normal, no murmurs or arrhythmias auscultatedLung sounds: normal BV sounds both sidesAbdominal palpation: comfortable, no abnormalities palpatedSkin: normalGenitals: normal, full GU exam not performedMusculoskeletal: ambulatory x4, no deficits noted in consult, full MSK exam not performedNeurological: BAR, no deficits noted, full neuro exam not performedTemperature: not takenLaboratory: many degenerate neutrophils, only occasional malassezia, no bacteriaAssessment: Inflammation of earsConsent has been given by the client to proceed with this treatment  -  YesPlan: Elocon 0.5mls SID into both ears - first tx instilled in consult with OPred 5mg SID for 5 days (accidently did 1/2 of 5mg SID but called O to clarify give ONE tablet - and dispensed 2.5 more tabs). Start tonightRecheck at Robina on Thurs as already has appt for final puppy vacc, or sooner if not improvingDiscussed potential causes of ear infections are allergies (food, atopy) vs due to his floppy ears/ increased moisture/ humidity - to monitor for ongoing ear +/- skin symptoms. Can trial ear cleaner 1-2x a week as maintenance if needed    Vital Signs    Weight: 9.8;       

Reason: 2nd Puppy Vax - $50 Off VoucherHistory:- presented for 2nd puppy vax- brought him home a month ago- Currently fed Royal Canin puppy biscuits -EDUD normal- Mild weeping from eyes noted by owner, not severe- no other health concerns-UTD parasite prevention Examination:- BAR- BCS 5/9- Cardiac: no murmurs or arrhythmia auscultated- Lung fields sound clear- Abdomen: soft, comfortable on palpation- Eyes, ears, dental normal- MSK: good mobility- One testicle descended, one not yet palpable- Mild ocular discharge present bilaterally- Ophthalmoscopic examination unremarkableAssessment:- Healthy puppy- Unilateral cryptorchidism (monitoring required)- Mild ocular discharge, likely environmentalTreatment:- Vaccination administeredPlan:- booster in 4 weeks- Monitor testicle descent - if not descended by 6 months, recommend early castration due to increased risk of torsion and neoplasia- Monitor ocular discharge - likely environmental irritation - Can socialise with known vaccinated dogs but avoid public spaces until final vaccination completed- Advised handling desensitisation for paws, ears and mouth--- 27/02/2026 09:58:42 AM MY9:Examinations - Resolved - The owner reported no issues sms sent--- 27/02/2026 09:59:28 AM MY9:Vaccinations - Resolved - The owner reported no issues sms sent    Vital Signs    Weight: 7.5;