C10023962 / invoice 10000

*CARE* possible ear infection
Consult - General
PRESENTING COMPLAINT:  
(Poss ear infection)

SUBJECTIVE/ HISTORY:
EDUF ok, well within self.
Shaking head recently.
  Appetite: (normal)
  Water Intake: (normal)
  Urination: (normal)
  Faeces: (normal)
  Current Medications: (carprofen bid, gabapentin bid, p[aracetamol bid, trazodone sid in AM)
  Vaccination Status:  (UTD)

OBJECTIVE/ EXAMINATION:
Temperature:(not taken)
Mentation (BAR) BCS:(5)/9
Hydration:(ok)
Mm pink and moist, CRT <2 sec
Dental:(not excamined)
Oral exam: (not examined)
Eyes: (nad)
Ears: (L ear NAD.
Rear - mild-mod inflam of canal, with milly purulent discharge present)
HR: () bpm, rhythm (), Mumur (), pulses ()
RR: () pm, effort (), Aus pulmonary fields ()
Abdominal palpation: (normal)
Integ: skin and coat healthy, no obvious lesions or lumps noted, normal skin recoil
Msk: (mild swelling of distal HL)
Peripheral LNs: (nad)
Neurological: a full neurological exam not performed

LABORATORY:
(Cytology:
R ear - yeast +, cocci +++, rods ++, keratinocytes +++, occasional neut.)

ASSESSMENT/ PROBLEM LIST:
(1. post-TPLO
2. unilateral ear infection)

DD's:
(1. post-TPLO
2. unilateral infection - suspected underlying allergies + E collar causing infection)

TREATMENT:
(Ketoconazole/enrofloxacin/dexamethasone in squalene solution.)

PLAN:
(Recheck 10-14d)

OWNER COMMUNICATION NOTES:
(Discussed with O'  difficulty in managing ears and post-TPLO - ideally want pred to reduce inflam in ear, but cannot while recovering from TPLO.
Start topicals for R ear and  recheck at suture r/o next week.)