C10010695 / invoice 10000

ear infection

Visit Summary: 

History:
- noticed a couple days ago 
- steroid for paws 
- shaking/ irritation 
- skin  ok, better when cooler 
- medicated washes 1x weekly
- 3 weeks into hypoallergenic trial 
- long term hx of ear issues 

Vaccination status: Up to date 
Parasite Control: utd 
Diet: on hypoallergenic 
Current Medication/Supplements:

Examination:
Demeanour:   BAR   MM pink moist crt<2     BCS:  /9  
HR:         RR:      T:   
Dental:  /5 
Cardiovascular:  No murmur or arrythmia.  SSFP.  Clear lung fields. No crackles or wheezes  
Abdomen:   Comfortable. No pain, fluid wave or abnormalties. No hernia 
Eyes: open and comfortable.  Nil eyelid, corneal/ anterior chamber changes.  
Nares: nil crusting or discharge 
Ears: erythema, increased yellow d/c esp in the R ear. stenosis and 2ndary changes. 
Orthopaedic:  Wbx4. Good mobility. Comfortable on ROM  
Neurological:  Appropriate mentation. Nil ataxia.  Nil nystagmus. Normal CP. 
Integument: overall healthy coat. No ectoparasites or lesions noted. 
LN: wnl
Rectal:

Diagnositics Tests Performed:
cytology 
- rods R ear ++++ 
- malasezzia L ear + 

Assessment/Diagnosis:   OE 


Plan/Client Communication:
- Discussed zenrelia trial, combined with cytopoint or separately 
- ordered in C4V script for EKT squalene 
- recheck in 14 days