C09977242 / invoice 10000

Reason: EarsConsult Nurse: RHHistory:Presented by DaleFirst noticed a few weeks agoO tried managing with ear cleaner but not improvingSome discharge from RIGHT eyeExamination:Thoracic auscultation - unremarkableAbdominal palpation - unremarkableLN - unremarkableOral exam - grade 1-2 109 ext? Gingivitis associated with toothOcular exam - irriatted, anisocoriaHydration status - adequateSkin exam - mass MGE - RIGHT eye lower eyelid mid to lateral canthus. Lesion is ulcerated and has lack of pigment. Some irritation on hind paws.Mass above LEFT eye, cystic?.Neurological exam Musculoskeletal examGenital exam - hooded vulvaRectal exam - nilAural exam - BOTH earsPinna - unremarkableMeatus - dark brown dischargeVertical canal - dark brown dichargeHorizontal canal - dark brown dischargeTypanic membrane - intactCytology - ear cytologyCulture and sensitivity - nilLaboratory:  Test: Ear cytology - BOTH earsResults:Diagnosis/Differential Diagnosis:Otitis externaMGE openTooth?Treatment: PMPPlan:Recheck ears in 10 days. Can line up recheck with eye surgerySurgical removal of lesion on RIGHT eyelid to prevent from turning malignant. X-ray of 109 and extract if needed. Full dental not required. FNA small mass above medial aspect of LEFT eyelid when under GA.Wash hind paws and perivulva area with Malaseb BIW for 2 weeks and leave on for 10 minsFlush eyes with tear solution to reduce irritation from massNon Surgical procedure:Ears cleaned with paw    Vital Signs    MMColour: Pink;       Temperature: 38.1;       HeartRate: 90;       BodyScore: 5;       DentalGrade: 1;       RespirationRate: 24;       CRT: < 1 sec;