C10029294 / invoice 10000

Appointment Notes: ear infection IPPrimary complaint/relevant information:  R ear worsehas had a few over the time they have had him, responds wellhas cortavance uses twice a week but compliance has dropped a little lately, O suspect why its gotten away from themSwimming all the time! Daily! Jumps in the pool as unfencedShaking head, pawing at ear/s (Right) Red, swollen, painful ear/s (Y/R externally pink/spotty)Discharge from the ears (Y can see brown exudate in R ear)Previous ear infections (Y/)Concurrent skin problems (N) EXAMINATION: Demeanour: BAR MM: Pink, moist, CRT <2 Eyes: Clean and clear, normal eyelids, no erythema or discharge Ears:External appearance: (R  brown discharge, erythematous/red spots inner pinna) Otoscope exam: (R ear brown discharge, moderate canal swelling at VC junction and mucosa red, TMs intact)L ear pink mucosa and scant brown exudate Lymph nodes: Peripheral lymph nodes palpably normal Oral: No oral lesions or abnormalities detectedTeeth: Dental grade 0/4, normal occlusion.Cardiovascular: Normal heart sounds, no murmurs or arrhythmias detected, femoral pulses synchronous and normodynamic Respiratory: No nasal discharge, normal bronchovesicular lung sounds in all 4 quadrants, no coughing seen Abdomen: Soft and comfortable on palpation, no masses palpated, bladder unremarkable MSK: Normal gait no lameness. Normal ROM with no pain of all limbs. No pain on DV palpation of spine Integument: Coat is soft and clean, no ectoparasites detected, no obvious skin lesions or masses Neurological: Normal mentation, no ataxia or CP deficits observed. Full exam not performed Reproductive/Urogenital: External genitalia normal in appearance Rectal: Not performed PROBLEM LIST: OE bilaterallyDIAGNOSTICS: Cytology:Left ear: (yeast 1+ ) Right ear: ( yeast 2+) ASSESSMENT/DDX: Otitis externa (both ears) Infection type (Malassezia/Mixed) PLAN:MEDICATION: Owner shown how to administer Dermotic 1.5ml per ear BID for 10 days, massage inCLIENT COMMUNICATION: Explained importance of recheckExplained prevention/home maintenance required- stop this for now while using dermoticNO swimming!Progress exam booked     Vital Signs    Weight: 31;