C10013787 / invoice 10000

Reason: Recheck Aural HaematomaDrained 3ml serum- instilled depomed, start oral pred 20mg sid as per planRV appt made, pay gap then    Vital Signs    

Verified: NoSubjective:Patient has a history of ear infections and a fungal infection in the ears. Recently developed a hematoma likely due to head shaking.Objective:T , BW kg, BCS /9HR: , MM pink, moist, CRT < 2secEENT - Fungal infection in ears, hematoma presentDENT - NADH/L - Normal rhythm, no murmurs. Pulses strong & synchronous. Normal RR & effort.ABDO - Soft, non-painful, no palpable massesUG - WNLMSK - NADNEURO - Gait & mentation normalOther issues - NoneAssessment:Ear fungal infection - diagnosed by swabEar hematoma - likely caused by head shaking due to ear discomfortPlan:Continue treatment for ear fungal infection.Drain hematoma and inject cortisone, repeat weekly as needed.Start oral cortisone at a low dose, monitor for side effects such as increased thirst, hunger, and weight gain.Advise owner to clean dog's feet after exposure to grass to manage contact allergy.Recheck weekly to manage hematoma and adjust treatment as necessary.    Vital Signs