C09977668 / invoice 10000

HistorySignalment: Female dogPresenting Complaint: Lexi presents for ear soreness and appearing "off" when waking upPatient History:- Lifelong history of recurrent yeast otitis, typically occurs approximately once yearly- Currently on oral supplements for gut bacteria to help manage ear issues- Recent hearing loss noted over past couple of months, worsening over past few days- Woke up seeming "off" but returned to normal when active- Head tilting noted this morning- Excessive hair in ears- Lives on property with deck access only, no exposure to grass seeds- Usually maintains regular grooming schedule but has been less consistent recently- Eating and drinking normallyExamVital Signs:Weight: --Temperature: WNLHeart Rate: WNLRespiratory Rate: WNLMucous Membranes: pink and moist CRT <2BCS: 3/5Findings:Eyes: NADEars: *Right ear more sensitive to examination than left, unable to visualise tympanic membrane OU due to hair and cerumen*Nose: NAD, no discharge bilaterallyOral: *Halitosis G 2-3/4 dental disease*Heart: NAD, reg rate and rhythm, no murmur auscultatedPulses: Strong and synchronousLungs: Clear lung fields bilaterally, no crackles or wheezes, normal resp rate and effortMusculoskeletal: No appreciable lameness, normal muscle mass/tone.Integument: NADPeripheral Lymph Nodes: WNL on palpationAbdomen palp: Soft, non-tender, no masses or organomegaly appreciableUrogenital: Normal external genitalia, NADRectal Exam: Not performedNeurologic: Full neuro exam not performed. Neurologic status appears WNLAssessmentProblem List::- Right ear yeast otitis - ddx yeast overgrowth, bacterial secondary infection- Halitosis - ddx dental disease, periodontal disease- Inability to visualise tympanic membrane - ddx cerumen impaction, hair obstructionPlanDiagnostics:- Otic swab performed: mild yeast infection confirmedTreatment Plan/Medications:- Rx: PMP otic medication for right ear- Epiotic ear cleaner provided- Instructions: clean ears today, wait 30 minutes, apply PMP, repeat cleaning in few daysCommunication::- Discussed inability to visualise eardrum and small risk of ototoxicity if tympanic membrane ruptured- Client declined sedation for deep ear plucking and thorough examination, opted to proceed with treatment- Discussed dental procedure estimate due to halitosis and history of extractions - est on file- Pre-anaesthetic bloodwork requested - will send to lab as prev increase in GGT to be checked - O will bring in 3-4 days before dental procedure (waiting as baby due in 2 weeks)- Noted historical mild elevation of liver enzymes but improved since August- Advised not to clean ears too frequently to avoid irritation    Vital Signs    Weight: 3.9;