C09978702 / invoice 10000

Reason: Ears - Sa HISTORY:  Presented for assessment of a suspected ear infection. The owner reports Boo swims frequently in the pool and goes to the beach on weekends. The issue started recently.Current medications: none advisedPre-existing conditions: noneAccess to toxins eg. Rodenticide: none EXAMINATION:Mentation: BARBehaviour concerns: not discussedBody Condition Score: 4/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically appropriateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation, normal bronchovesicular sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: Clinically normal ambulation, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no oral pain identified, dental score (1-4): not graded- Abdominal: no detectable pain or other significant abnormalities on abdominal palpation- Rectal: not performedUrinary: No significant findingsReproductive: No significant findingsIntegument/Ears: Right ear canal is erythematous on otoscopic examination. Superficial inflammation is also noted around the external ear and scabs. The left ear canal is clear.Lymph Nodes: No significant findingsEyes: Both eyes normal in appearance and comfort, no significant blepharospasm, proptosis or other extraocular abnormalities PROBLEM LIST:- Otitis externa (right ear) DIAGNOSTICS:Cytology Malassesia 3/4ASSESSMENT:Boo presented for a suspected ear infection. Examination revealed erythema of the right ear canal and surrounding pinna, cytology was consistent with malassezia otitis externa. The left ear appears normal. TREATMENT:  Dermotic prescribed: apply 0.5 mL in and around the right ear twice daily for one week.PLAN:Advised to keep the ear dry for the next week, which includes no swimming. Re-evaluation 7 daysHome into owner's care.    Vital Signs    Weight: 22.7;       

    Vital Signs    

Reason: Redo X-Rays - No ChargesAppointment Notes: ------- Sms reply: YHISTORY:Recheck 5 weeks post-fracture. The cast was removed one week ago.The patient is currently on crate rest and lead walks for toileting only.Owner reports the patient is feeling better but has noticeable muscle wastage. They are asking if hydrotherapy/swimming is appropriate.EXAMINATION:Musculoskeletal: Significant muscle atrophy noted on the affected limb. Ambulation is managed with a lead.DIAGNOSTICS:Radiology : Digital radiography was performed.Interpretation: Radiographs of the previous fracture site show good callus formation and progression of healing. A very small fracture gap is still evident.Lateral radiograph is slightly blurry however can visualise what is needed. ASSESSMENT:Recheck post-fracture. Healing is progressing very well based on radiographic assessment. Significant muscle wastage is present on the affected limb, which is expected.PLAN:Continue crate rest and short lead walks for toileting for at least one more week.The plan will be confirmed after consultation with specialists at SASH. Radiographs will be sent to them for review.The owner was advised that swimming may be beneficial for rebuilding muscle mass as it is a non-weight-bearing exercise. This will also be confirmed with the specialists.Will contact the owner today after speaking with the specialist to finalise the ongoing management plan.ADDENDUM: Spoke with Specialist re Boo's latest radiographs- Fracture looks fantastic and should be stable to remain out of the bandage. - The abnormal hyperextension laxity of the hock will improve with more weight bearing. - Will continue to rapidly heal out of the bandage dt bone stimulation- Lead walks only but build up slowly over next 2 weeks. Avoid running and jumping but does not to be confined to the crate anymore. - Approved for swimming.    Vital Signs    Weight: 15;