C09971359 / invoice 10000

Reason: Ear Issues - See AEC HxAppointment Notes: Overdue remindersHistory: Jacki is a 5 year and 8 month old male neutered Jack Russell Terrier presenting for possible ear infection. O reports that Jacki has been O started panadol last night Cytopoit inj 20mg L or R ear? Both mentioned in notesPresented to AEC last night, started on panadol, opted to revisit today for ear cytology + medsOtherwise well? Had cytopoint, apoquel + zyrtec before for atopyDiet + appetite: eating and drinking wellUrination/defecation: normalPreventatives: UTDAny issues: no other concernsExamination: Demeanour: BARHeart: 100Resp: 30BCS: 5/9MM: p+m, CRT <2Mouth: C0G0, normal occlusion, no cleft palate MSK: able to ambulate well, normal gaitNeuro: normal mentation, no obvious cranial nerve deficits or ataxiaEyes: clear, normal menace response and palpebral reflex, responds to visual cuesEars: bilaterally stenotic erythematous ears with dark waxy exudate, malassezia +++ bilateral on cytology Abdo: no pain on palpationInteg: clearLaboratory: Ear cytology - malassezia +, cocci + L ear, clear R ear Assessment: Otitis externaTreatment: NilConsent has been given by the client to proceed with this treatment  -  YesPlan:O to monitor, revisit if concerned Auracol 1ml each ear BID 7 daysRecheck in 10 days for repeat cytologyReason: Nurse: -vaccination -heartworm -worming -flea/ticks Exam: Lab: Assessment: Treatment: Plan:    Vital Signs