C09971244 / invoice 10000

Appointment Notes:  VETSTORIA -  - Nala (Dog) - India Furse - 0402167617 - Consult - Eyes, Skin, Ears [Clinician : Dr Andres Townsend ( Senior Surgeon )(No Preference)] - Sudden swollen ear -Web BookingPrimary complaint/relevant information:  Disease onset Progression and duration: Current Medications: None  Medical conditions: None  Appetite: Energy Levels: Exercise/Exercise intolerance: Vomiting: Diarrhoea:  Weight loss/gain: Thirst: Urination: Coughing/Sneezing/Respiratory signs: Diet:  Flea/tick:  Worming: Indoor/outdoor: Toxin exposure: Travel history: Shaking head, pawing at ear/s (Left/Right/Both) Red, swollen, painful ear/s (Y/N)Discharge from the ears (Y/N)Previous ear infections (Y/N)Concurrent skin problems (Y/N) EXAMINATION: Demeanour: BAR MM: Pink, moist, CRT <2 Eyes: Clean and clear, normal eyelids, no erythema or discharge Ears:External appearance: (bilateral brown discharge, erythematous) Otoscope exam: (brown discharge, canal swelling, TMs intact/not visible)Lymph nodes: Peripheral lymph nodes palpably normal Oral: No oral lesions or abnormalities detectedTeeth: Dental grade 0/4, normal occlusion. COHAT Level Estimated: (A, B, C, D, E) Cardiovascular: Normal heart sounds, no murmurs or arrhythmias detected, femoral pulses synchronous and normodynamic Respiratory: No nasal discharge, normal bronchovesicular lung sounds in all 4 quadrants, no coughing seen Abdomen: Soft and comfortable on palpation, no masses palpated, bladder unremarkable MSK: Normal gait no lameness. Normal ROM with no pain of all limbs. No pain on DV palpation of spine Integument: Coat is soft and clean, no ectoparasites detected, no obvious skin lesions or masses Neurological: Normal mentation, no ataxia or CP deficits observed. Full exam not performed Reproductive/Urogenital: External genitalia normal in appearance Rectal: Not performed PROBLEM LIST: N/A DIAGNOSTICS: Cytology:Left ear: ( ) Right ear: ( ) ASSESSMENT/DDX: Otitis externa (L ear/R ear/both ears) Infection type (Bacterial/Malassezia/Mixed) PLAN:MEDICATION: Owner shown how to administer CLIENT COMMUNICATION: Explained importance of recheckExplained prevention/home maintenance requiredTREATMENT: Handouts given: Ear infections Top 10 handout Progress exam booked Verified: NOHISTORYPresenting for: India, a 9-10 year old female dog, presented for evaluation of a swollen ear suspected to be an aural haematoma.Historical Conditions:- Chronic pruritic skin condition with seasonal flare-ups (worse in warmer months/spring and summer)- Previous Malassezia ear infections (multiple episodes)- Mild arthritis- Blood test approximately one year ago with normal results- Recent relocation from Gold Coast to Gatton via LaidleyDiet:- Black Hawk dry kibble with chicken and brown rice- Appetite remains normal- Recent weight loss attributed to increased exerciseCurrent Meds:- Apoquel (on and off for 2-3 years, currently cycling on/off as needed for skin condition)- Previous Cytopoint injections (worked for few months then became ineffective)- Simparica for flea/tick prevention - up to dateSkin:- Chronic allergic skin disease with seasonal pattern- Currently showing mild redness and spotting- Condition generally under control at present but fluctuates- Suspected environmental allergies (possibly grass)V/D/C/S:- Recent head shaking behaviour- Mild ear odour noted by owner last nightLifestyle Risk Factors:- Recently moved from large rural property to smaller yard, now receiving increased daily walks- Country environment with potential grass allergen exposureEXAMMentation: BARWt: Recent weight loss noted (attributed to increased exercise)T: 36.9°CBehavioural: Cooperative during examination, accepted treats readily, calmer than usual (owner noted she typically barks at strangers)Ears: Aural haematoma present affecting one ear, causing ear to flop down. Bacterial infection identified in both ears on cytological examinationIntegumentary: Mild erythema and spotting consistent with allergic dermatitis, currently relatively well controlledMusculoskeletal: Mild arthritis noted, mobility good for ageDiagnostics: Ear cytology performed - bacterial infection (cocci) identified bilaterallyASSESSMENTAural haematoma - likely secondary to head shaking from bilateral bacterial otitis externa. Treatment options discussed including conservative management with steroids versus surgical interventionBilateral bacterial otitis externa - bacterial infection identified on cytology, likely contributing to head shaking behaviour that precipitated haematoma formationPLANDiagnostics:- Complete blood panel sent to external laboratory ($232) to assess suitability for steroid therapy, results expected today or tomorrowNew Meds/Tx:- Ear drops prescribed for bilateral otitis externa: 1ml each ear twice daily for 10 days, followed by 4 days without treatment- Anti-inflammatory tablets (steroids) for haematoma: 1 tablet once daily for 7 days, then 0.5 tablet once daily for 7 days, then 0.5 tablet every second day until finished. Treatment duration several weeks with possibility of incomplete resolutionAdditional Discussion:- Conservative steroid treatment chosen over surgical intervention as first-line approach- Surgical option remains available if conservative management fails or haematoma worsens- Needle drainage not recommended due to risk of continued leakage and trauma- Elizabethan collar may be considered if head shaking persists but not routinely recommended due to patient discomfortClient Comms:- Will contact with blood results today or tomorrow, may adjust treatment plan based on results- Recheck appointment scheduled in 2 weeks to assess treatment response- If haematoma enlarges or fails to respond to steroids, surgical intervention will be recommended- Discussed risk of cauliflower ear formation if left untreated, which could compromise ear canal patency    Vital Signs    Weight: 36.9;