C10028245 / invoice 10000

Sore ears

History:
Reason: Ear infection
Diet: not discussed
Preventatives: not discussed
Medications: stilboestrol 1mg once weekly
EDDU: normal
Coughing/Sneezing: no
Vomiting/Diarrhoea: no
Current Diagnoses: Recurrent ear infections, USMI
Hx:
Patient has history of recurrent ear infections, particularly when weather is hot and humid. Owner reports current left ear infection. Previous ear infections have been treated successfully with antibiotics and ear drops. Owner is comfortable administering ear drops at home. Patient has not shown signs of head tilt, funny walk, or balance issues. Owner has some leftover ear drops at home that were used but didn't seem effective.

Examination:
DEMEANOUR: anxious
MENTATION: BAR
GENERAL: BCS: 7/9; HR: 96; RR: pant; MM: p,m; CRT: <2; T: not taken
EARS: left ear erythematous and mild lichenification, right ear unremarkable externally
EYES: no discharge or erythema
NOSE: no discharge
ORAL: no discharge or halitosis; 0/4 dental disease, worn teeth
CV: no murmurs or arrythmias
RESP: clear bronchovesicular sounds on all fields with normal effort
ABDO: comfortable; no palpable abnormalities
UROGEN: no discharge or swelling
MSK: normal gait
NEURO: no gross abnormalities
DERM: no external parasites; good coat; no lesions, pruritus or erythema
LYMPH: no peripheral enlargement
RECTAL: not assessed

Problem list:
aural inflammation
head scratching/shaking

Diagnostics:
 Otoscopic Examination - graded out of 3
Left: erythema (++), stenosis (+), discharge (+) that is (brown); TM (intact, no visible FB)
Right: erythema (nil), stenosis (nil), discharge (nil) that is (nil); TM (intact)

Aural Cytology
Left ear: yeast (3-5)/HPF, cocci (nil)/HPF, rods (nil)/HPF, neutrophils (nil)/HPF, many squames present
Right ear: yeast (nil)/HPF, cocci (nil)/HPF, rods (nil)/HPF, neutrophils (nil)/HPF 

Assessment:
left malasezzia otitis externa

Client Communication:
Discussed ear infection treatment protocol including 2 week minimum treatment course. Explained importance of ear cleaning twice weekly during infection, allowing 30-60 minutes drying time before medication application. Provided ear cleaning chart for tracking treatments. Discussed use of syringes to prevent contamination of ear cleaner bottle. Explained steroid use for reducing inflammation and pain, potential side effects including increased hunger/thirst and possible worsening of incontinence. Discussed long-term prevention plan using compounded Cortavance and Austrazole combination medication at estimated cost of $150-160 lasting 40 weeks. Scheduled recheck in 2 weeks.

Treatments:
nil

Plan:
otoflush ear cleaner: use twice weekly when infected; fill the ear with the cleaner, massage well and gently wipe away the excess; leave 30-60 minutes before instilling medication
apex PMP: instill (1)ml left ear BID (14) days
prednisolone (20): give (1) tablet orally ONCE daily for (10) days
progress exam 14 days with aural cytology - consider cortavance/austrazole combination product

Discharge Instructions:
Clean ears twice weekly during infection, allow 30-60 minutes drying time before applying medication. Apply 1ml ear medication to left ear twice daily. Give prednisolone tablet once daily with food. Use provided chart to track treatments. Return in 2 weeks for recheck. Contact clinic if any concerns arise.

staples out of chest

Wound appears to be healed with no evidence of erythema or discharge.

Staples removed. No further rechecks required unless O concerned.

dog fight minor

History:
Reason: (DFW)
Diet: (not asked)
Preventatives: (not asked)
Medications: (nil)
EDDU: (normally)
Coughing/Sneezing: (no)
Vomiting/Diarrhoea: (no)
Current Diagnoses: (nil)
Hx:
(DFW < 24 hours old on the chest.)

Examination:
DEMEANOUR: (nice but nervous)
MENTATION: (BAR)
GENERAL: BCS: (7)/9; HR: (88); RR: (pant); MM: p,m; CRT: <2; T: (40.0)
EARS: no discharge, swelling or erythema
EYES: no discharge or erythema
NOSE: no discharge
ORAL: no discharge or halitosis; (0)/4 dental disease, worn teeth
CV: no murmurs or arrythmias
RESP: clear bronchovesicular sounds on all fields with normal effort
ABDO: comfortable; no palpable abnormalities
UROGEN: no discharge or swelling
MSK: normal gait
NEURO: no gross defecits noted
DERM: no external parasites; good coat; 2.5cm laceration through skin to the left cranial sternal area
LYMPH: no peripheral enlargement
RECTAL: not assessed

Problem list:
(DFW)

Diagnostics:
(Nil)

Assessment:
(DFW)

Client Communication:
(KH admitted for stitch up, given estimate ~$1000. O has consented to treatment.
AH called after assessment and advised the wound was stapled and ok to be discharged with take home NSAIDS and ab's. Remove staples in 2 weeks. Discussed risk of dehisencse, infection, etc.)

Treatments:
(Clipped and flushed wound - it is a fresh wound and is clean, only through the skin, so the decision was made to staple. Patient was tolerant of this. 
Stapled wound
Meloxicam 0.2mg/kg SC (based on lean wt of 65kg))

Plan:
(Home with amoxyclav 12.5mg/kg PO BID for 7 days
Home with meloxicam 0.1mg/kg PO SID starting tomorrow night.
Staples to be removed in 2 weeks)

Discharge Instructions:
(Nil)