C09993841 / invoice 10000

Appointment Notes: VETSTORIA - Arthur (Dog) - Khloe Campbell - 0459762666 - Consultation [Clinician : Dr Ainsley Van Egmond(No Preference)] - Ear infection (New client) - Web BookingClient name: Khloe CampbellContact number: 0459762666Email address: khloe_campbellx@icloud.comPatient name: Arthur?????History:Presented for intense pruritus of the ears, which began yesterday. Owner reports approximately one to two previous ear infections, typically yeast, occurring in summer after swimming. Has a history of digestive issues as a puppy, with an intolerance to chicken causing diarrhoea. Occasionally vomits bile if he refuses a meal. Owner reports he is otherwise well.- Significant history: Previous episodes of otitis externa. Known dietary intolerance to chicken.- Current medications: "Black rose" gentle ear cleaner, which owner believes causes irritation.- Appetite & diet: "A billion bar" and Prime 100 Turkey Kangaroo sausage.Examination:Vital Signs: BAR, HR WNL, RR WNL, Temp WNL, MM pink, CRT <2sec, Skin tent WNL- Eyes: No blepharospasm, no conjunctival hyperemia, no epiphora.- Ears: Bilateral otitis externa. In-house cytology revealed cocci in both ears and rods in the right ear. No yeast identified. No significant biofilm present. Canals cleaned in-clinic.- Oral: Grade 1 dental disease, affecting molar teeth.- Nose: NAD.- Cardiovascular: No murmers or arrythmias.- Respiratory: Clear broncivesicular sounds on all lung fields.- Skin: Normal coat, no ectoparasites.- Abdomen: Soft, no masses palpated.- MSK: Ambulating normally. WBx4, good ROM all joints. No spinal pain.- Lymph nodes: Submandibular, pre-scapular and popliteal LNs WNL.- Urinary/Genital/Rectal: Not assessedAssessment:Problem List:* Bilateral bacterial otitis externa (cocci AU, rods AD)* Grade 1 dental disease* History of dietary intoleranceTreatment:* Bilateral ear clean performed in-clinic.* First dose of otic medication administered in-clinic.Plan:* Dispense otic medication. Instil 0.3 mL into each ear canal twice daily for 10 days.* Recheck consultation in 10 days for repeat ear swab and cytology.* At-home dental care: recommend brushing molar teeth weekly.* Preventative ear care: recommend cleaning ears every two weeks and after swimming once infection has resolved.Client Communications:Discussed cytology findings, noting that rod bacteria can be more resistant to treatment. Advised that if the infection does not resolve, an ear swab for culture and sensitivity will be required. Instructed owner on correct administration of ear medication, emphasising the use of a new syringe for each ear for each dose to prevent cross-contamination. Advised owner to cease all ear cleaning for the 10-day treatment duration. Discussed dietary caution regarding turkey protein due to known chicken intolerance. Owner confirmed understanding and consented to the plan.?????    Vital Signs    Weight: 11.6;