C09977197 / invoice 10000

PRESENTING/OWNERS CHIEF COMPLAINT/REASON FOR VISIT: ()

Consult Nurse: (-)

History:
EDDU normal
No V+ or D+ (N)
Diet: (Cont. as per previous)
Vaccinations: (Due tomorrow - do at recheck in 1 week.)
Preventatives; 
Worming: (UTD)
Heartworm: (As above)
Flea & Tick: (UD)
Current Age: (4y3m)
Current Medications: (Nil at home)
Behaviour Concerns: (Been quieter than usual)
History: (Been quiet / depressed last 2-3 days. Had consult with Richard Burchell - see notes. Eating well. Has had some weight loss. Drinking well. Holding head down on the left side. Seems uncomfortable. some dark d/c in ears. No similar concerns recently. Was prev. in adelaide and didn't have any other issues. )

Physical Exam:
BAR; (Y)
Behaviour: (QAR)
HR: (80); RR: (NAD, ~32/ pant);  T: (Not taken); MMC: (PM); CRT: (<2s);
Hydration: normal
BCS: (4)/9
EENT: (eyes clear, no evidence of conjunctivitis, no discharge or blephrospasm); (Dark d/c bilateral ear canals, mild stenosis.); (no nasal discharge); (grd 1) dental disease -- small amount staining rostral molars)
Cardiac: (normal rate and rhythm, no murmurs on auscultation)
Resp: (normal rate, normal clear sounds auscultated in all lung fields)
Abdo: (comfortable on abdominal palpation, no palpable abnormalities)
Urogenital: (grossly normal)
Integument: (no external parasites noted; no erythema or pruritis)
Neuro: (proprioception NAD; NSF)
Musk: (ROM in all joints NAD; no abnormalities on palpation)
Ln's: (LHS submandibular LN enlarged. non painful. Rest of PLN's normal)

Client Communication from Consult Nurse:
(NA)

Client Communication with Vet:
(Discussed 
- causes; enviro predisposition & breed/ etc. 
- R. burchell discussed ddx of hypoadrenocorticism -- discussed use of steroids for otitis externa and how this may affect hypoA 
- Discussed GIT upset recently -- avoid PO anti-inflammatories/ steroids. )

Laboratory/Imaging:
NA

Assessment/Problem list:
(Otitis externa)

Treatment:
Dexamethasone 2mg/mL 1.5mL 3mg 0.1mg/kg
PMP 1mL ea. ear 

Client Communication with Vet:
(Assess response to steroids.)

Plan:
(GHC in 6mths)

Internal treatment plan Comms:
()

Follow up notes:
(Recheck 1 week for ear clean and palpate LN's. Discuss cortisol/ ACTH stim for hypoA tx - has had dex. will need to wait until cleared from system

)
Follow up phone called for for () days