C09981152 / invoice 10000

Appointment Reason: Check Ears, Appointment Notes: recheck ears JOHISTORY: Check on bilat OEEar pruritus pain much improvedPedal pruritus resolvingNormal appetite and demeanourCURRENT DIET: RC Anallergenic; Prime 100 Kangaroo /Boar/Turkey/CrocodileV beef allergic PREEXISTING CONDITIONS:  Food intoleranceCURRENT MEDICATION:  fluoxetine 30mg SID  : Clonidine 150ug x 1 for groomingPE:T-Not takenHR/CARDIAC-No murmur NSRRR/RESP-Normal lung sounds and resp effortMM-NCRT-NLNN-NABD-NBCS- 6/9 Ideal BW approx 9.5kgOTOSCOPY/EARS: Allowed brief otoscopy R ear : mod erythema, mild swelling and brown debris inner pinna and entrance to vert canal. Some dried blood with debris at entrance to vert canal.  Vert canal and hrz canal briefly examined - mild erythema/swelling.  Would not allow deep otoscopy to assess TM. Pain much improvedL ear : mild erythema, swelling and debris inner pinna only. Will not allow deep otoscopy to assess TMORAL HEALTH: Gr0 -1EYES: NMSK: Bilateral medial patellar luxation  Gr1-2 LHS, Gr2 RHSasymptomatic INTEGUMENT: V mild erythema ventral forepawsUROGENITAL: NCNS: Not routinely examinedPROBLEM LIST:Bilateral malass OE - improvingSuspect malass hypersens (low numbers but severe inflammatory response R ear ) Mild pododermatitis- resolvingAllergic skin disease - atopic dermatitis most likely Patellar luxationRX:Will not allow any topical rx by owner Poloxamer Gel 1.5ml each earPred 5mg SID4d, 2.5mg SID4d Fluconazole 50mg SID  (on order) for 14d total then twice a week for 1mthRecheck Tues next week INB - consider sedation/GA and ear check/clean Discuss Zenrelia at recheck     Vital Signs