C10008915 / invoice 10000

had acp at 6am 1.5 tabs ACP 10mg (dispensed elsewhere, label is very faded but says to give half a tablet)Patient Information:Caesar BreckenridgeDate of Examination: 06/03/2026Subjective:Presenting for right ear infection.Owner reports worsening signs over several days, including head tilt. Owner attempted treatment with over-the-counter ear drops (Lillium) from a pet shop and another product bought online, but administration was difficult.History of cruciate ligament repair surgery. Owner reports stiffness in the operated leg, particularly after rest. Hydrotherapy has been beneficial in the past.Dietary history: Not discussed.Objective:Physical examination findings: very sedated, cannot walk unassisted. impossible to assess gait. all incisions from left TPLO and mass removal surgery are healed, no obvious swelling in hind legsRight ear examination reveals a severe bacterial infection with significant crusting and purulent discharge. Otoscopy performed. A small scab is noted on the pinna of the right ear, consistent with self-trauma from scratching. No foreign body detected in the ear canal.Diagnostic tests performed: Ear cytology (right ear) shows a mixed bacterial infection with rods and cocci. left ear nsfAssessment & Plan:1. Right Ear Bacterial Otitis ExternaAssessment: Severe bacterial otitis externa of the right ear canal, likely secondary to underlying allergies and/or moisture exposure. The infection is an overgrowth of normal flora.Treatment plan: Ear paste applied in-clinic today. Follow-up nurse appointment scheduled for next week for a second application of ear paste. Recheck with a veterinarian the week after to assess resolution.Follow-up care: Monitor for signs of improvement or worsening.2. Post-operative Cruciate Ligament Repair stiffnessAssessment:Likely developing arthritis in other joints (hips, spine) due to age.Treatment plan: Discussed initiating Cartrophen injections to slow the progression of arthritis. This involves weekly injections for four weeks, followed by maintenance injections every three months. The owner is considering this option and will discuss familyFollow-up care: Continue with hydrotherapy as it provides excellent support for joint mobility without weight-bearing stress. A multimodal approach (hydrotherapy + therapeutic agents) is recommended.Additional Notes:Owner education on the diagnosed condition(s): Educated owner on the nature of otitis externa as an overgrowth of normal flora, often triggered by moisture or allergies. Discussed the mechanism of Cartrophen as a joint protective agent to slow arthritis progression.Any specific owner concerns addressed during the consultation: Addressed concerns regarding sedation for procedures. The owner administered one and a half tablets of ACP medication this morning (three times the recommended dose), resulting in significant sedation during the consultation. Advised that for future consultations, half a tablet 4-6hours prior is sufficient. o states she has used ACP for PVPs with us previously although we have not dispensed this. advised we will see how caesar goes on half a tab (5mg) and go from there06/03/2026 1:06:03 PM ECV: Vetpay today, whole amount.    Vital Signs