C10031645 / invoice 20000

Re-check post- Otitis externa (to be used if seen within the last month, otherwise full consultation fee) History: Refer previous visit CURRENT MEDICATION: Last given/administered EXAMINATION:L ear R ear LABORATORY: L ear R ear Plan:    Vital Signs    

Reason: Waiting OutsideAppointment Notes: VETSTORIA -  - Miles Smithson (Dog) - James Smithson - 0402757788 - Consult (1 concern) [Veterinarian : Consult 2(No Preference)] - Ear infection in right ear, and potentially in left -Web BookingClient name: James SmithsonContact number: 0402757788Email address: jamessmithson312@hotmail.comPatient name: Miles SmithsonHistory:  Miles Smithson presents for ear scratching and previous redness- History of multiple ear infections- Previously treated with Mometamax- Required sedation for previous ear cleaning due to non-compliance- Had concurrent dental work requiring sedation- Ear redness noted on weekend (Saturday), improving since then- Currently scratching at ears- Attends daycareCURRENT MEDICATION: EXAMINATION:BAR - VERY wiggly but nice boy Easiest way to look in ears was to lift up front end and minimal restraint on head L ear: mild debris at base of Canal - TM that can be visaulised in tact R ear NAD - TM in tact Bilaterally no cardinal signs LABORATORY: L ear  NAD R ear  NAD COMMUNICATION: - Explained no current infection found on cytology- Discussed possibility of allergic reaction causing ear inflammation- Advised steroids may reduce inflammation and improve tolerance for ear cleaning- Client informed that if head shaking continues, re-examination and possible treatment may be needed- also discussed that middle and inner ear pathology no examinable in GP - Emphasized avoiding unnecessary antibiotics to prevent resistance- Demonstrated restraint technique for future ear medication administrationDIFF DX: - Ear inflammation - ddx allergic reaction, early infectionPLAN: - Rx: Steroids for inflammation (low dose, few days)- Ear cleaner discussed but deferred due to patient's aversion to ear manipulation    Vital Signs    Weight: 26;