C09983425 / invoice 10000

Reason for visit: ear infection and check lump/wart

HISTORY
Has had ear problems before, uses a cleaner. Recently has had more discharge and is itching/shaking head. Also noticed small lump on RFL near elbow.

EXAMINE 
BAR
PE - WNL except:
 - moderate brown discharge both ears (L > R) - cytology yeast 3+
 - small red, raised lump on RF elbow - FNA showed round granular cells

ASSESSMENT
Lump ddx: histiocytoma (most likely given age), MCT
Otitits externa yeast

TREATMENT
Dermotic BID for 7-10d both ears + epiotic for cleaning

PLAN
Offerred removal vs monitor lump as likely histiocytoma, O happy to monitor for now.
Recheck ears in 7-10d

Reason for visit: licking, itchy

HISTORY
Last week or two has been licking front paws a lot, a little red.
EDDU normally no issues. 


EXAMINE 
Eyes: NAD
Ears: NAD
Oral Cavity: PM <2s
Teeth: good G0
Heart: NAD
Lungs: NAD
Lymph Nodes: NAD
Ab. Palp: NAD
Integument: lick staining front paws palmar surface. worst on right side, otheriwse skin normal 
Musculoskeletal: NAD
Neuro: NAD
Urogenital: NAD

ASSESSMENT
mild pruritus front paws, likely allergy or irritation. rest of skin currently okau. Can trial topicals and INI consider systemic options

TREATMENT
Malaseb twice weekly, alloveen conditioner 

PLAN
Consider Cytopoint or steroid course INI

Reason for visit: lepto booster

HISTORY
Due for lepto booster
Also wanting ears checked - had ear infection, looking much better
Otherwise wel EDDU normally

EXAMINE 
Eyes: NAD
Ears: mild brown discharge yeast+
Oral Cavity: PM <2s
Teeth: Clean
Heart: NAD HR 120
Lungs: NAd panting
Lymph Nodes: NAD
Ab. Palp: NAD
Integument: NAD
Musculoskeletal: NAD
Neuro: NAD
Urogenital: NAD

ASSESSMENT
fit for vaccination 
mild ear infection

TREATMENT
continue dermotic at home for a further 5 days then recheck. 
Showed cleaning and dermotic application in consult. 

PLAN
Due lepto vaccination in 12 months