C09990325 / invoice 10000

Reason: Ears - TSHistory-Update:Consent has been given by the client to proceed with this treatment  -  Yes/NoReason: Nurse: NG-vaccination  C5 due 24/03/26-heartworm  NGS-worming  NGS-flea/ticks   NGSHISTORY:  Presenting for a recurrent infection in the left ear. Also concerns regarding white stuff at the start of bowel motions. Current medications: none advisedVaccination: Due for C5 vaccination in 3 weeks.Pre-existing conditions: Recurrent otitis externa.Access to toxins eg. Rodenticide:none EXAMINATION:Mentation: BARBehaviour concerns: not discussedBody Condition Score: 4/9Pain Scale (0-4): 0/4 Hydration 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: Nails were trimmed.Gastrointestinal:- Oral: normal, no oral pain identified, dental score (1-4):not graded- Abdominal: no detectable pain or other significant abnormalities on abdominal palpation- Rectal: Anal glands were full and were expressed.Urinary: No significant findingsReproductive: No significant findingsIntegument/Ears: Left ear is pruritic with excessive yellow discharge.Lymph Nodes: No significant findingsEyes: Both eyes normal in appearance and comfort, no significant blepharospasm, proptosis or other extraocular abnormalities PROBLEM LIST:- Otitis externa (left ear)- Full anal glands DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:- Bacterial and yeast otitis externa- Impacted anal glands ASSESSMENT: Honey presented for a recurrent left ear infection. Examination and cytology confirmed a mixed Malassezia and staphylococcal otitis externa. The owner's concern about white material in the faeces was investigated via rectal examination, which revealed full anal glands. These were expressed, which is expected to resolve the issue. Nails were also trimmed. TREATMENT:  Neptra was instilled into the left ear canal.Nails were trimmed.Anal glands were manually expressed.PLAN:Recheck consultation scheduled in three weeks.Administer C5 vaccination at the next visit.Home into owner's care    Vital Signs