C10009993 / invoice 10000

Infection
Pet Insurance Provider & Policy No (if applicable & not provided): Bupa

Presenting problem: Problem with the ears & hot spots behind ears

Hx:
Worming up to date (Y)
Heartworm up to date (Y)
Flea & Tick control up to date (Y)
Check other reminders due (Y)

Clinical:
Demeanor = Bright Alert Responsive
TPR = Normal Vitals = WNL
Eyes = Normal and Healthy 
Teeth Grade (1) Dental Required? (N)
Ears = see below
Heart Ausc = Normal Sounds & Rhythm, No murmurs or arrhythmias noticed
Lung Ausc = Normal Sounds
Abdo. Palp = Unremarkable. No painful response or distension noticed
Lymph nodes = Normal and Healthy. No swellings 
Skin = dermatitis on head & neck 
MSK = Normal and Healthy. No lameness or Soreness
Weight = Normal
Rectal = NAD
 
Laboratory: 
Cytology (ear swab) reveals Malassezia, Bacterial Infection (Cocci)

Diagnosis: 
Otitis externa (R/L) ear
Hotspots dermatitis on head from scratching

Treatment: 
Start treatment with Surolan
Oral antibiotics = Cephaelxin 
Cleaned ears 
Ear cleaning solution = otoflush
Mediderm 
Neocort
Consent has been given by the client to proceed with this treatment  -  Yes

Plan: RC ears in 1 week 

Client Comms:
Dr Don Called 
No Answer left message to call back