C10009345 / invoice 10000

Reason: Courtesy Phone Call
Nurse: Bessie
Grass seed in nose removed by Murdoch
ttponalm

HISTORY
Presenting for: Maple presented with acute onset sneezing and bleeding from the nose whilst on a walk. No swelling, collapse, or vomiting noted.
V/D/C/S: Sneezing, intermittent with light blood-stained serous discharge from left nostril.

EXAM
Mentation: BAR
MM: Injected, moist. CRT 1-2 seconds.
Nose: No swelling to face or muzzle. No bee stings or foreign bodies found in or around mouth, lips, or tongue. Nose slightly skewed to left side. Intermittent sneezing with light blood-stained serous discharge from left nostril. Irritation noted in nasal passages.
Oral: Attempted oropharyngeal exam with limited visualization.

ASSESSMENT
Suspected foreign body (grass seed) in left nostril

PLAN
Diagnostics:
- General anaesthesia recommended for investigation of left nostril and potential foreign body removal.

Client Comms:
- Advised that GA required for investigation
- Referral to overnight care for anaesthesia and hopeful recovery of foreign body

HISTORY
Presenting for: Canine patient Maple presented for annual checkup, vaccination, Heartworm injection, and recent pruritus with history of seasonal allergies.
Historical Conditions: Last Cytopoint in March. History of seasonal allergies.
Diet: Royal Canin dry food only, BID with occasional carrot stick for teeth.
Current Meds: No current medications.
Other: Owner reports patient is well and healthy at home. No health concerns.

EXAM
Mentation: Lovely and relaxed
BCS: 4/9
HR: 120
Ears: Mild to moderately inflamed ear canals with mild build up of brown waxy debris. Cytology revealed clumps of Malassezia in both ears.
Oral: Light to moderate tartar on upper carnassials. Remainder of teeth clean with no gingivitis.
Cardiovascular: No heart murmur.
Respiratory: Lungs clear. Breathing normal.
Abdominal: Soft and comfortable on palpation. No palpable masses.
Integumentary: No palpable masses over body.
Musculoskeletal: Gait WNL. No lameness.
Diagnostics: Ear cytology: Clumps of Malassezia in both ears bilaterally.

ASSESSMENT
Bilateral otitis externa - Malassezia infection
Mild dental disease
Seasonal allergies - Currently pruritic
Otherwise apparently healthy

PLAN
Vaccinations:
- Kennel cough vaccination administered today
EAGs today - full, expressed normally. 

New Meds/Tx:
- ProHeart injection 0.3 mL SC administered today
- Cytopoint 10 mg SC administered today
- Dermotic 0.5 mL BID in both ears for 10 days

Client Comms:
- Recheck ears after 10 days of treatment
- Will decide if Elocon is indicated at recheck
- Noted patient doesn't have recurring ear infections, so Elocon may not be necessary