C10003795 / invoice 10000

Reason: Lump In EarReason: Client Present: AngelaNurse: PKJasper came in today for a lump inside his right ear, noticed two days ago. O doesn't believe it is bothering him at all. EDUD normally, UTD with vacc and simparica trio at homeHealthy Pets Wellness Testing: Done Yes / NoVaccination Type: UTDIntestinal worming: ^^Heartworm Prevention: ^^Flea Prevention: ^^Tick control: ^^Microchip: On fileInsurance and Healthy Pets Plus: InsuranceBehaviour concerns: No concernsCurrent medications:Current Diet:Type of Shampoo/Frequency: NilToileting: No concerns__________________________________________________________________________Reason: Assessment of ears.Client Present: Owner present.Healthy Pets Wellness Testing: Not discussed. Current Diet: Not discussed.Type of Shampoo/Frequency: Regularly groomed, but unsure if new groomer cleans ears.Toileting: No concerns noted.History: Presented for assessment of ears. History of scratching at ears and head shaking. The owner also reports Jasper chews on his paws occasionally. No previous history of ear infections.Examination: Demeanour: Bright, alert, and friendly.Temperature: Not taken.Hydration Level: Adequately hydrated, pink mucous membranes, good skin tent.Eyes, Ears, Nose, Throat: Otoscopic exam revealed yeasty debris and inflammation in both ears. The left ear appears worse, being more moist. A nodule was noted in the left ear canal. Eyes, nose, and oral mucosa appear unremarkable.Capillary Refill Time/Mucous Membranes: Pink, CRT <2 seconds.Oral exam/Calculus level (0-4): Not performed.Cardiovascular/Heartrate: HR: 90 normal rate and rhythm. No murmur auscultated. Pulses strong and synchronous.Pulmonary/Respiratory: RR: normal rate and effort. Lungs clear on auscultation. Peripheral Lymph nodes: WNL.Abdominal Palpation: Soft, non-painful.Urogenital: Male, neutered status not confirmed.Rectal: Not performed. Skin/Integument and Nails: Thick coat. Mild interdigital erythema noted on one paw.Musculoskeletal/Neurologic function: Ambulatory, no obvious deficits.Muscle Condition: Good muscle condition. Pain Score (0-5): 1/5 (mild discomfort/itchiness). Laboratory: Ear cytology recommended to determine if yeast or bacteria are present.Assessment:1. Bilateral otitis externa: Likely yeast overgrowth. The left ear is more severely affected.2. Left ear canal nodule: Likely secondary to chronic inflammation. Differential includes inflammatory polyp or histiocytoma.3. Pododermatitis: Mild erythema suggestive of allergic or inflammatory cause.Treatment:Ear cytology (cytology) to be performed in-house to guide treatment.Therapeutic ear clean.Consent has been given by the client to proceed with this treatment - verbal consent obtained for ear cytology and cleaning. Plan:1. Perform ear cytology to identify infectious agents. Yeast only in both ears2. Perform a thorough ear clean under supervision to demonstrate technique to owner.3. Dispense appropriate ear medication based on cytology results. Dermotic 1ml into each ear 2 times per day4. Discussed that the nodule is likely inflammatory and may resolve with treatment of the otitis. If it persists, surgical removal could be considered, possibly at the same time as a future procedure like a dental scale and polish.5. Monitor for continued paw licking/chewing.6. Recheck examination if signs do not improve.    Vital Signs    Weight: 18.7;