C10021296 / invoice 10000

Reason: Possible ear infectionAppointment Notes: nohc, both ears are red and hot bleeding after scratching, shaking head - CCSFHISTORY:Tank presented for ear infection concerns. Owner reports ongoing ear issues with scratching and discomfort. Previous soft palate correction surgery has not been performed. Owner notes vomiting episodes which may be related to elongated soft palate causing airway obstruction and mucus buildup.EDDU: Not mentionedCurrent meds: noneVaccination: Not mentionedParasite Prevention: Not mentionedPre-existing conditions: Brachycephalic obstructive airway syndrome (BOAS) - elongated soft palate uncorrectedAccess to toxins eg. Rodenticide: noneEXAMINATION:Body Condition Score: not mentionedPain Scale (0-4): not mentionedHydration status (%): not mentionedCardiovascular: 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: bilateral ear infection with inflammation and swelling, yeast and bacteria presentLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: not discussedPROBLEM LIST:Bilateral ear infection with yeast and bacterial overgrowthBrachycephalic obstructive airway syndrome with elongated soft palateIntermittent vomiting episodesDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Bilateral otitis externa with secondary yeast and bacterial infectionBrachycephalic obstructive airway syndromeDIAGNOSTICS:Ear swab performed to identify causative organismsASSESSMENT:Tank presented with bilateral ear infection showing inflammation and swelling with yeast and bacterial overgrowth. Physical examination revealed elongated soft palate consistent with brachycephalic obstructive airway syndrome which may be contributing to vomiting episodes. Ear swab confirmed mixed infection requiring topical antimicrobial therapy.TREATMENT:Topical ear medication prescribed for twice daily application for five daysEar cleaning recommended prior to medication application using liquefying ear cleanerOwner advised to complete full course of antibiotics even if improvement noted after 2-3 daysPLAN:Continue prescribed ear medication twice daily for five daysRoutine ear cleaning once to twice weekly for maintenanceRecheck appointment available if no improvement notedConsider specialist referral for BOAS surgery evaluation including soft palate correctionReturn for ear swab if future infections suspected to avoid antibiotic resistanceCLIENT COMMUNICATION:Owner educated regarding brachycephalic obstructive airway syndrome and elongated soft palate contributing to vomiting episodes. Discussed specialist surgery options for soft palate correction. Advised on proper ear cleaning technique using liquefying ear cleaner before medication application. Emphasised importance of completing full antibiotic course and avoiding unnecessary antibiotic use to prevent resistance. Owner instructed to return if ear infection symptoms persist or worsen.    Vital Signs    Weight: 11.7;       HeartRate: 100;       DentalGrade: 1;       RespirationRate: pant;       CRT: 1-2;       MMColour: pink, moist;       BodyScore: 5;