C10012454 / invoice 10000

Reason: Drain Ear Hematoma Appointment Notes: O has noticed Ear Hematoma - would like to drain if possible.Reason: Name of Client Present: JeorjaTBC Nurse Initials: CDClient Concerns: Drainage of Ear Hematoma Vaccination:Both are dueParasite Prevention: (Product Name:   ) (Last Given:   )Microchip # & Behaviour Indicator filled in: Yes/NoInsurance / Healthy Pets Plus:Is patient on any medication? NoCurrent Diet:Product:Feeding schedule:Laboratory Testing Needed:_____________________________________________________________HISTORY:Sunny presented for repeat drainage of left aural haematoma. Owner reports improvement following initial drainage and anti-inflammatory treatment with massage therapy as instructed. Fluid accumulation has recurred over the past week but noted to be lesser volume than previously. Appetite slightly decreased but owner attributes this to being more selective with food preferences.EXAMINATION:Body Condition Score: 6/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): not graded- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: Left aural haematoma presentLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: not discussedASSESSMENT:Sunny presented for repeat drainage of left aural haematoma. Physical examination revealed recurrent fluid accumulation in left ear, though lesser volume than initial presentation. Owner reports good response to previous drainage and anti-inflammatory treatment - would like to continue with conservative management like this instead of surgeryTREATMENT:Topical lignocaine cream applied for five minutes for local anaesthesia. 18G catheter inserted and 17mls serosanguineous fluid drained from left aural haematoma. 2mg dexamethasone (1ml) instilled into haematoma cavity.PLAN:Monitor response to treatment. Return in approximately two weeks for reassessment and potential repeat drainage if required. Continue monitoring at home.    Vital Signs