C10021894 / invoice 10000

ear infection

Reason: Consult
Client(s) present ()
Room ()

NURSE: Pre-Examination Discussion: 
Diet (typle, brand, frequency, treats (advance and raw), Supplements ()
    Recommendation/discussion ()
Parasite prevention (product, last given (nexguard spectra)
    Recommendation/discussion () 
Vaccination status? (C7 vaccination UTD)
    Recommendation/Discussion ()  
Other/lifestyle (delayed desexing) 
Microchip on file ()

VET: Medical History:
Presenting Problem (Ears)
Symptoms (gunky discharge, smelling)
Onset (one week)
Previous episodes/history of (has previously had ear infections)
EUDD normally (yes) 
Previous or current medical concerns/conditions (NIL) 
Current Medications (has been using ear drops)

Clinical Examination:
Habitus (BAR)
Eyes (nsf, clear, PLR palpebral normal)
Ears (bilat dark waxy discharge, pinna erythema)
Mouth/nose/MM (MM pink moist, CRT <2)
Teeth / Dental Disease Grade (0/4)
Skin (nsf, good coat condition, skin grossly normal and free of lumps, lesions and ectoparasites)
Lymph Nodes (wnl,no lymphadenopathy)
Heart auscultation (HR regular, no detectable murumr or arrhythmia)
Lung auscultation (RR normal, regular effort, lung field clear)
Abdomen (nsf, soft and comfrtable on palpation, no appreciable internal lumps or abnormalities)
Genitourinary (ne)
Temp (ne)
Rectal (ne)
Gait (nsf, comfortable and weightbearing evenly when ambulating)
Musculo-skeletal (nsf, normal and comfortable joitn exam)
Neurological (normal mentation)
BCS (5/9)

Assessment:
(otitis externa - painful around ears 

Client communication:
(Discussed cyotlogy and treatment, given pain around ear and concurrent discussed sedated ear clean and assessment, neptra if active infection. Given second infection and already unhappy with ears being touched advised this can ensure we identify infection correctly, assess the tympanic membrane and apply medication as needed, est given for 680 - owner have consented to treatment today.  )

Admitted: Groom

Pre-GA exam:
Demeanour (BAR)
Chest HR(80)bpm, RR(24)bpm
Temperature (38.3)C
MM (pink), CRT(<2s)

Sedation; administered () at ()
  Medication/doses; (butorphanol 0.3mg/kg 0.44mL, medetomidine 10mcg/kg 0.22mL), (1300)
  Level of sedation (moderate)
  Sedation top up (NIL) 

Cytology - no yeast or bacteria seen 
ears flushed with epiotic and cleaned 
Dexason, flamazine, otoflush mix made and administered to give once weekly for maintenance