C09980709 / invoice 10000

Reason: R Ear InfectionAppointment Notes: Overdue remindersReason: Name of Client Present: GlenTBC Nurse Initials: CLClient Concerns: Thinks ear infection in Right ear- tilting head to side, no shaking or scratching but yelps when O touchesVaccination: UTD Parasite Prevention: Nexgards spectra- most likely due this monthMicrochip # & Behaviour Indicator filled in: YesInsurance / Healthy Pets Plus: Bow Wow MeowIs patient on any medication? NoCurrent Diet:Product: Tub "D & D" pet food and dry food grain freeFeeding schedule: Morning and night Laboratory Testing Needed:_____________________________________________________________History: head tilt since yesterday. Not shaking or scratching. Otherwise been well. Has been in grassy areas recently. Multiple lumps on bodyExamination: muzzled for ears. Chest sounds clear. Discharge and pain on swab (R>L). Not able to examine otoscopically conscious. Back for sedation to examine ear later in the day.Sedated exam. Chest sounds clear. Abdo palp normal. Obvious but not enlarged spleen. Fatty lumps on torso, all mobile. Small black lump back of L hock, approx 3mm diameter. Skin tag like. Another similar but pink on RH metatarsis area. Very mild tartar on a few teeth, rest of oral cavity NAD. LN's NADL ear mild discharge, TM normal. Cleaned with otoflush. R ear inflammed, mildly stenotic. Could initially see half of TM, but wax/debris obscuring the second half. Did not look to be a grass seed (no the right shape) but similar in colour. Flushed ear with otoflush, no longer able to see TM post flushing. No GS seen after either. Laboratory: L ear cytology normalR ear occ budding yeast, cocci +++, neuts ++TAHP sending offAssessment: OE with poss otitis media. Have ketoconazole/triamcinolone long acting ear gel from BOVA in the fridge, was for another patient that no longer needs it so used as safe for ruptured TM.Lumps all appear to be benign. Treatment: compounded BOVA ear meds 2.5mL down R earAmoxyclav 375mg BID starting tonightPred 30mg SID for 6 daysConsent has been given by the client to proceed with this treatment - YesPlan: administer another dose of ear meds in 1 week. To recheck TM would need another sedation in future given temperament, otherwise avoid swimming etc for 6 weeks. INI with head tilt may need CT scan to look for FB or do C&S if current treatments not effective.Call with blood results once back    Vital Signs    MMColour: Pink;       Weight: 28.3;       HeartRate: 120;       BodyScore: 6;       DentalGrade: 0-1;       RespirationRate: Norm;       CRT: <2;