C09980718 / invoice 10000

poss ear infection

Consult 

History: 
Reason for presentation: (Scratching at the ears, Only noticed from last night as he tends to not scratch while owners are home. Has had ear problems recurring in the past every few months.)

Diet: (Dog biscuits)
Eating: (Y)
Drinking: (Y)
Toileting: (Y)
Diarrhoea: (N)
Vomiting: (N)

Vaccinations: (UTD)
Chip Scan: () 
Insurance (Y/N - Policy # )
Flea control: (Done at home, should be UTD)
Heartworm: ()
Worming: ()
Nails: ()
Medications: (Owner's partner (not present) put an ear ointment in last night, unknown brand suspected PMP from last treatment OR otoflush?)

Concerns: (Just ears) 


Clinical exam:
Demeanor: (BAR)
Temperament: (Lovely dog)
Heart: Rate (132) Rhythm: (normal) Murmur (no) Femoral pulse (-) 
Respiration: (40)
Oral exam: Teeth (1/4) MM (pink) CRT (2s) Moisture(moist)
Eyes/Ears/Nose: (eyes and nares are clear, free of redness, discharge, inflammation. Ears are mildly inflamed internally, with red-scabbing on the skin [most likely scratch wounds]. No visible discharge visible in ears, but ear canals reddened when viewed with otoscope + painful to dog)
Skin/coat: (clear and clean)
Abdomen: (soft on palpation)
Musculoskeletal: (normal RoM, ambulates well)  
Genitals: (-)
Temperature: (38.7)
Lymph nodes: (No enlargements palpated)
Rectal: (-)
BCS: (5/9)

Problems: (Possible ear infection)

Diagnostics tests: (Ear cytology:
L.Ear = Cocci FEW, more than R.ear but still not many
R.Ear = Cocci FEW, 1 yeast seen total)

Dx: (Low grade ear infection + traumatic injury to ear.)

Treatment: (Given Meloxicam 10ml bottle, to give 6.5-7kg dose SID with food for 5 days)

Plan: (Owner to continue cleaning with ear products at home - Owner believes it is Oticlean. Once daily for a week, reassess how the ears are going after this. Owner will return for recheck if still scratching at the ears after this for medication. Meloxicam should help with inflammation and pain from scratching, and let the ear canals narrow for easier cleaning. Owner aware that if it doesnt resolve with medication, FB could be possible - not seen today though with otoscope.)