C10006472 / invoice 10000

Reason: GHC Unwell??Appointment Notes: Overdue remindersHISTORY:  Presented for sore eyes and ears. The owner reports a possible altercation with another dog. The other dog frequently licks inside Stax's ears. Stax shakes his head upon waking, with audible fluid sounds in the ears. The eyes appear very sore, with some bleeding noted. He frequently scratches his face on the carpet. There is observed weakness in the hind limbs, with occasional collapse. Appetite and toileting are normal. History of a surgically corrected disc prolapse several years ago. Current meds: noneVaccination: Not mentionedParasite Prevention: Not mentionedPre-existing conditions: History of surgically corrected disc prolapse.Access to toxins eg. Rodenticide: none EXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): not discussedHydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory:thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological:Ambulates with mild hind limb weakness but gait is not significantly abnormal. No other overt neurological deficits noted.Musculoskeletal: Mild hind limb weakness observed.Gastrointestinal:- Oral: normal, no mouth pain, dental score (1-4):not graded- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: AD Purulent discharge AS nil.Lymph Nodes: NSFEyes: OS mucopurulent stringy discharge. Demeanour/Behaviour: not discussed PROBLEM LIST:- Otitis externa (right ear > left ear) with haemorrhage- Ocular discharge/inflammation, secondary to ear pathology vs. primary ocular disease- Hind limb weakness- Suspected deep cranial/ear canal abscess DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:- Severe otitis externa/media, potentially with self-trauma.- Traumatic injury to the ear canal.- Suspected deep cranial abscess or mass.- Keratoconjunctivitis Sicca (Dry Eye).- Recurrent or new spinal pathology causing hind limb weakness. DIAGNOSTICS:Ear cytology AU:AS: Proteinaceous debris + mild amount of degenerate segmented neutrophils.  Potentially some cocci in small quantities.AD: Neutrophillia segmented 20-30 per HPF.  Cocci in small quantitiesFurther diagnostics discussed:- Schirmer Tear Test to be performed at recheck if ocular signs do not improve with ear treatment.- CT scan of the head recommended if no significant improvement on current treatment, to investigate for a deep abscess or mass. ASSESSMENT: OE + KCS vs just OEVs intra-cranial abscessation from a burst neoplastic lump + subsequent abscessation. TREATMENT:  Ears were cleaned by nursing staff.Medication prescribed: Unnamed ear medication, one pump into the affected ear once daily for five days. First dose administered in clinic. Owner provided with gloves and instructions for home administration.Advised owner they can use over-the-counter human lubricant eye drops (e.g., Systane) in the interim to soothe the eyes. PLAN:- Continue ear medication once daily for 5 days.- Re-evaluation scheduled for Thursday (after 3 doses).- If significant improvement (e.g., >95% reduction in signs) is not seen by the recheck, a CT scan will be strongly recommended.- If ears improve but eyes do not, a Schirmer Tear Test will be performed at the recheck.- Home into owner's care. CLIENT COMMUNICATION:Discussed the possibility of a simple but severe ear infection versus a more serious deep cranial abscess. Explained that the cytology results are concerning for the latter. The plan to treat for a severe infection for 3-5 days was outlined. If there is no marked improvement, referral for a head CT scan is the next step. The potential high costs (several thousand dollars) and guarded prognosis associated with a deep abscess requiring specialist surgery were discussed. Advised to monitor for improvement over the next 3 days and return for a recheck on Thursday. Instructed on the administration of ear medication and the use of lubricating eye drops.    Vital Signs