C09993081 / invoice 10000

Follow up appointment to check ear drum -
Vetstoria Appointment
Consult - General
PRESENTING COMPLAINT:  
(Receck ears)

SUBJECTIVE/ HISTORY:
O' currently stuck overseaaso, brought in by parents today.
Finisghed steroid ointment in R ear on Monday.
Finisghed ear ointment into L ear a few weeks ago.
EDUF ok, well within self.
No scratchign or jhead shaking seen.
  Appetite: (normal)
  Water Intake: (normal)
  Urination: (normal)
  Faeces: (normal)
  Current Medications: (nil)
  Vaccination Status:  (UTD)

OBJECTIVE/ EXAMINATION:
Temperature:(not taken)
Mentation (very BAR) BCS:(5)/9
Hydration:(ok)
Mm pink and moist, CRT <2 sec
Dental:(nad)
Oral exam: (nad)
Eyes: (nad)
Ears: (R ear - NAD.
L ear - very comfortabl to examine, though mild crumbly cerumen within horizontal canal, and cannot visualise TM.)
HR: (104) bpm, rhythm (normal), Mumur (nil), pulses (synchronous)
RR: (panting) pm, effort (nil), Aus pulmonary fields (normal)
Abdominal palpation: (comfortable)
Integ: skin and coat healthy, no obvious lesions or lumps noted, normal skin recoil
Msk: (not examined)
Peripheral LNs: (nad)
Neurological: a full neurological exam not performed

LABORATORY:
(Cytology:
L ear - keratinocytes ++)

ASSESSMENT/ PROBLEM LIST:
(Mild inflam L ear)

DD's:
(Mild inflam L ear)

TREATMENT:
(1. continue elocon/mometasone into RIGHT ear once weekly.
2. dexamethasone in squalene SID 10-14d into LEFT ear.)

PLAN:
(Recheck 10-14d.)

OWNER COMMUNICATION NOTES:
(Discussed with Elyse over the phone - she advised sig bloody D+ when on steroids, so discussed all options - opted to start dexamethasone/squalene mix for l ear and then continue elocon/mometasone lotion into R ear.
Recheck 10-14d.)