C10009476 / invoice 10000

RIGHT ear looks greatLEFT ear NADboth ears no dicahrge nd nothing at all on swab-  no cytology as nothing to put on slidesedated .11 dom/.1 torb - mild moderate sedationplucked ears. examiend ears, some light hairs down canal otherwise NADflushed ears epi-oticPLANto STO re ears - would be a great candidate for 2-4 weekly ear flush and cortavance down ears for long term preventative; would also like to do a diet trial but can wait until O life more under control, esp as clinical signs are mildcan stop dermotic after 7 days. will caht to O to see of happy to do ear cleans/cortavance at home, or we can do as a nurse consult in clinic if neededrec pluck - next time instead of heavy sedartion could trial gabapentin, sp dog can get used to itvery minimal reaction with moderate sedation todaySmall Animal ConsultationHISTORYPresenting problem:Onset/Duration/Progression:Vaccines/Preventatives (F/T/W/HW):Meds/Supplements:Diet:EDDU:Energy/Behaviour:Previous medical history:Owners Concerns:MAIN FINDINGS OF PHYSICAL EXAMDemeanour:TPR:MM/CRT:BCS:Heart / Lungs auscultation:Eyes / Ears:Nose / Oral Cavity:Abdominal palpation: Musculoskeletal:Neuro: Mentation / CNs / ReflexesLymph Nodes:Skin/Coat/Genitals: Rectal (if indicated): ASSESSMENTDiagnostics: Problem List:Differentials (Dx): Clinical interpretation: Prognosis: Good / Fair / Guarded / PoorTREATMENTPLAN    Vital Signs    Weight: 13.4;