C09990986 / invoice 10000

05/03/2026 PROCEDURE - Check ears

Pre Anaesthetic Examination: HR 80        CRT 1-2sec         MM pink, moist          RR panting
General Anaesthetic:
 - Premed - acp/meth IM  @9.16am
 - Induction - Alfaxan IV @ 9.43am

Procedure: EUA
Lt canal clear with a small amount of brown waxy material near TM. TM intact, no FB present.
Rt ear clear, no dishcarge. GS at the end of horizontal canal near TM. - Removed. TM intact. Small amount of bleeding from mucosa after GS removal.

Good recovery.

Treatment: Dermotic bid Rt ear for 5 days to control inflammation and prevent infection formation. 

Post-operative Instructions:
Home care Recommendations:
 
Remind/Recall/Revisit:
1 day - FUC - Reception


05/03/2026 History:
Acute onset head shaking and scratching at L ear since this morning 
Owner attempted to look into the ear with a torch and did not see anything.
Dog lives on nearly 2 acres with grass seeds present on the property.
Breakfast given at 07:00 today (about 1/2 a cup of kibble).
Drank water around 07:45-07:50 today.
No vomiting or diarrhoea within the last 48 hours.
Owner suspects a grass seed may be involved.
Insurance is in place.

Any other concerns: N
On any medication: Meloxicam PO SID, Gabapentin 300mg PO BID, Clomipramine 25mg PO BID. Given ~7-7:30am 
Changes in behaviour: Head shaking
Changes in eating/drinking: N
Changes in activity levels: N
Changes in toileting: N

Routine Health Care:
Microchip Checked: Microchip checked: Yes
Vaccinations Up to Date: Y
Vaccinations Next Due: September 
Intestinal Worming Up to Date: Y
Intestinal Worming Product: NGS
Heartworm Prevention Up to Date: Y
Heartworm Prevention Product: NGS
Flea Prevention Up to Date: Y
Flea Prevention Product: NGS
Diet History: About 1/2 a cup of kibble given at 07:00 today.
Pet Insurance: Owner reports active pet insurance; clinic to submit a gap claim after billing.

Physical Examination:
Temperature: Not performed 
Pulse: 80
Respiratory Rate: Panting 
Blood Pressure: Not performed
Body Condition Score /9: 5
Dental Grade: 0
Thoracic auscultation: NSF
Abdominal palpation: NSF
Eyes: NSF, corneas appear clear and free of discharge, pupils normal size, globes symmetrical OU
Ears: Patient exhibited head shaking during attempt to examine ears while awake. Full otic examination deferred due to patient movement.
Oral Cavity: NSF, no tartar or gingivitis present, pink and moist mucous membranes, CRT <2 sec.
H/Lymph: NSF
Skin: NSF, skin appears normal; hair coat in good condition, no ectoparasites noted
Musculoskeletal: NSF
Urogenital: NSF
Neurological: NSF
Pain Score (/10): 1

Routine Investigations:
Haematology: Not indicated today; recent blood work performed a month ago per owner.
Biochemistry: Not indicated today; recent blood work performed a month ago per owner.
Ear cytology: Indicated if no FB found in either ear

Assessment:
Differentials: Possible aural foreign body (e.g., grass awn). Otitis externa is also a consideration given pruritus and head shaking. Definitive assessment pending otoscopic examination under sedation or anaesthesia.

Plan:
- Admission for sedated otoscopic examination - remove any FB if present 
- Ear cytology if no FB present

 RRR Details:
Remind/Recall/Revisit: Hospital vet to call with otoscopic examination results after sedation .