C10006960 / invoice 10000

REASON: Ear pain and head shakingTime: 8 AMAES Vet: Dr Madeleine HearndenRegular clinic: TVHBHISTORY:- Owner concerned about head shaking and refusal to allow touch near the ears, particularly the left ear. This has now extended to sensitivity in the right ear.- The symptoms worsened last night after the owner attempted to instil an ear cleaner into the left ear, which caused a significant reaction.- Presented this morning upon waking with very rapid head shaking- Twitching was observed overnight while sleeping, with head shaking commencing immediately upon waking.- The owner is concerned they may have aggravated the condition by using the ear cleaning product, which is kept on hand but not used routinely.- No scratching of the ears has been observed.- The patient has been seen yawning which is a new behaviour - Past medical history includes an allergic reaction seen at AES over a year ago, nasal surgery, a previous grass seed in an ear that required sedation for removal after a three-week course of treatment, and an eye ulcer. Has had BOAS surgery. - Known to be difficult for veterinary examinations, especially around the head and face.- No other current medications.- Otherwise well, with no vomiting or diarrhoea.- Did not have breakfast today but has had a drink of water.TRIAGE:Mentation BARMinimal examination prior to sedation due to aggression and reactivityPatient growling, lip-lifting, lunching and snapping/bitingWeight: 13 kgBody Condition Score: 4.5/9Respiratory: Normal respiratory effort, no nasal drip Neurological: Appropriate mentation, no ataxia. Cranial nerve function and proprioception not able to be examined.Musculoskeletal: Ambulating normally without gait abnormalities.Gastrointestinal: No pain or reaction on palpation of abdomen EXAMINATION: (Post-sedation)HR: 64 bpmRR: 20 brpmTemp: 38.2 degCMM: Pink and moistCRT: 1-2 secPulses: normalPeripheral temperature: warmPain Scale: 4/24Cardiovascular: No murmurs or arrhythmias, strong synchronous femoral pulses.Respiratory: Clear lung sounds auscultated bilaterallyGastrointestinal:- Oral: Not examined due to ongoing reactivity, even post-sedation.- Rectum: no rectal examination performedUrogenital: Unremarkable.Integument/Ears/Eyes: External ear canals have mild cerumen accumulation bilaterally with no strong malodour. Post-sedation otoscopic examination revealed both ear canals have minimal erythema down to the tympanic membranes. Both tympanic membranes are intact. Both ears had a mild plug of hair at the level of the eardrum & mild fluid accumulation. Lymph Nodes: peripheral lymph nodes normal size/shape and not painfulASSESSMENT:1. Otitis / Allergic Otitis- Findings of head shaking, ear pain, and hair plugs within the ear canals are suggestive of otitis, likely secondary to atopic dermatitis or another allergic skin condition rather than a primary infection or foreign body, as per the exclusion of these diagnoses with testing. - Otoscopic examination performed under sedation. Both ear canals showed minimal erythema. Plugs of hair were found at the level of the tympanic membranes bilaterally and were removed. The tympanic membranes were intact.- Cytology of cerumen samples showed no evidence of Malassezia/yeast or bacteria indicating no infection present - Treatment initiated to reduce inflammation and manage pruritus.- Sedation was required for examination and procedure due to reactivity.- Further management with the regular veterinarian for long-term control of suspected underlying atopic dermatitis was recommended.CLIENT COMMUNICATION:Discussed the plan for sedation with the owner to allow for a thorough ear examination, which they consented to. Explained risks of sedation without examination, owner understands risks. The procedure was prolonged due to the patient's reactivity, requiring adjustments to the sedation protocol. The owner was kept informed throughout and was understanding.Following the procedure, the findings of hair plugs in the ears were explained, with no evidence of infection or grass seeds. It was advised that this is likely related to an underlying allergic skin condition like atopic dermatitis. The dispensed medications are to manage the current inflammation. The owner was strongly encouraged to follow up with their regular veterinarian to discuss long-term management options, such as Apoquel or Cytopoint, or any topical anti-inflammatory medication that may be approrpiate long-term for Otto. Instructions for all take-home medications were provided. Advised to keep Otto quiet for the rest of the day as he may remain somewhat sedated, and some dogs may experience some nausea form this. The owner was thankful and happy with the plan.DIAGNOSTICS:- Ear Cytology: Sample of cerumen viewed under microscope: debris only, no yeast/bacteria or atypical cells seen. TREATMENT:Initial sedation with dexmedetomidine at 7.5 ug/kg IM and butorphanol at 0.25 mg/kg IM - difficult to inject due to aggressive behaviour, resulted in only mild sedation, with the patient remaining reactive, lunging, and attempting to bite.Further sedation was administered with dexmedetomidine at 2.5 ug/kg IM and ketamine at 3 mg/kg IM, achieving moderate adequate sedation for the procedure. Patient muzzled. Otoscopic examination performed bilaterally (see above). Hair plugs removed with alligator forceps. Canals flushed with otoflush.Reversed with atipamezole 0.1 mg/kg IMGiven dexamethasone 0.1 mg/kg IM injection.PLAN:- Follow-up with regular veterinarian within one week for recheck and discussion of long-term management for suspected atopic dermatitis.- Return sooner if any concerns arise.- Keep quiet for the remainder of today - Medications prescribed:    * Chlorpheniramine: 4 mg PO Q8H for 4 days.    * Gabapentin: 200 mg PO Q8-12H as needed for sedation/anti-anxiety/pain relief.    * Prednisolone: 10 mg PO Q24H for 4 days, then 10 mg PO Q48H/EOD for 4 days. First dose to be given tomorrow, 24 hours after the dexamethasone injection.- Pre-visit medications dispensed for future appointments: gabapentin 200mg and trazodone 75mg PO 90-120 mins prior to veterinary appointments-----------------CURRENT MEDICATIONS DISPENSED:1. Prednisolone (steroid, anti-inflammatory) - Please give HALF a tablet ONCE daily for 4 days, then HALF a tablet every other day until finished. Tablets have been pre-halved for your convenience. NEXT DUE: Sunday AM2. Chlorpheniramine (anti-histamine) - Please give ONE tablet three times daily (every 8hrs). NEXT DUE: When able/ASAP3. Gabapentin (pain relief, sedation IF NEEDED) - Please give TWO capsules two to three times daily (every 8-12hrs). NEXT DUE: When neededPRE-VISIT SEDATION PROTOCOL:90 minutes to 2 hours prior to veterinary visits, give: Gabapentin (100mg) - Give TWO capsules + Trazdone (50mg) - Give ONE and a HALF tablets Expeced to cause sedation    Vital Signs    Weight: 13;       

HISTORY:Swelling of muzzle/ periocular area – started more sutbly about an hour ago then got worse  muzzle looked a little swollen In care of housesitter & friend ___, Os in EuropeNo changes in breathing / resp rate noticed at home but panting & stressed on arrival at clinic- normally has Trazadone + sedation for vet visits as reactive and stressed, doesn’t cope well TREATMENT:*CARE* reactive/ anxious – had to be towel wrapped for injectionsGiven 0.2ml butorphanol and 0.5mls histamil IM by hospital vetEXAMMinimal exam possible – more settled after TOrb & histamil and with O holding but still anxious & reactiveQAROMM pink, moist - CRT (owner) <1sPeriocular & muzzle oedemaNo urticaria or skin lesionsRR on presentation (stressed) - pant with mild effort/ brachy stertorPost torb & histamil when more settled- RR 28, normal effortChest auscult unremarkable, clear BV sounds bilaterally, no murmurCLIENT COMM: discussed pros & cons of in hosp monitoring overnight given _’s stress levels in hospital & with unfamiliar people handling vs monitoring at home tonight & BB if concerned- O elected to moniotor at homeTREATMENT:TGH on Iramine 8mg 1 tab BID -TID x 3 daysPLAN –  Keep indoors & rested tonight at home, monitor for reoccurrence of facial swelling / symptoms of  over next 24hrsBB if any changes in resp rate or effort, if becoming more lethargic or if  any concerns DISCHARGE:The exact cause of your pet's allergic reaction is not known, but common causes include insect stings, plant reactions and vaccinations.  A corticosteroid and an anti-histamine have been administered to stop the reaction from worsening.  The swellings/welts should resolve over the next 24 hours, however some animals can have a delayed type of allergic reaction as well, which means the signs can return after 24-48 hrs - if this happens, or you r are otherwise at all concerned, please have your pet rechecked by your vet or the AES.  These allergic reactions tend to reduce in severity as animals get older, however your pet may have more reactions like this in future.  Please keep your pet observed and rested over the next 12 hours.  After this, your pet can return to normal exercise and eating regimes. The exact cause of your pet's allergic reaction is not known, but common causes include insect stings, plant reactions and vaccinations.  A corticosteroid and an anti-histamine have been administered to stop the reaction from worsening.  The swellings/welts should resolve over the next 24 hours, however some animals can have a delayed type of allergic reaction as well, which means the signs can return after 24-48 hrs - if this happens, or you r are otherwise at all concerned, please have your pet rechecked by your vet or the AES.  These allergic reactions tend to reduce in severity as animals get older, however your pet may have more reactions like this in future.  Please keep your pet observed and rested over the next 12 hours.  After this, your pet can return to normal exercise and eating regimes. ________________________________________________    Vital Signs    Weight: 12.2;       MMColour: Pink;       BodyScore: 5;       RespirationRate: 28;       PainScore: 0;       

    Vital Signs