Veterinarian
History:
* Presenting complaint: "Coco" (Canine, Staffordshire Bull Terrier, entire male, 4 years old) presented for a 3-day history of scratching his left ear and shaking his head. Owner reports a reddish discharge noted this morning.
* Duration: 3 days.
* Background information: Coco is an indoor/outdoor dog, up-to-date on vaccinations, and has no known allergies. No recent changes in diet or environment. He has a history of occasional ear infections, typically responding well to topical treatments.
[List of current medications]
* Pre-emptor (Afoxolaner/Milbemycin oxime) – monthly, last given 25 October 2024.
* Nexgard Spectra (Afoxolaner/Milbemycin oxime/Praziquantel) - monthly, last given 20 October 2024.
Examination:
Body condition = 4/9 (ideal)
Weight = 25.4 kg
Dental exam = Mild tartar noted on canines and premolars.
Demeanour = Bright, alert, and responsive; slightly head-shy when left ear approached.
Oral mms-Pink, moist, CRT <2 seconds
Chest auscultation-Heart rate 110 bpm, strong, regular rhythm. No murmurs or arrhythmias detected. Lung sounds clear and vesicular.
Respiration-Eupnoeic, no increased effort. Respiratory rate 20 breaths/minute.
Abdominal palpation-Soft, non-painful, no organomegaly or masses detected.
Lymph nodes-Peripheral lymph nodes non-enlarged.
Mentation-Alert and appropriate.
Skin/coat-Coat is shiny and well-maintained. Mild erythema and excoriation noted around the left external ear canal.
Eyes-Clear, no discharge, pupils responsive to light.
Ears-Left ear canal erythematous with a moderate amount of reddish-brown, waxy discharge. Mild swelling of the pinna. Right ear appears normal.
[Temperature]
Rectal examination-Not performed
Laboratory:
* Left ear cytology: Abundant cocci bacteria and moderate numbers of Malassezia yeast. Occasional neutrophils noted.
Assessment:
* Otitis externa, left ear, consistent with bacterial and yeast overgrowth secondary to inflammation.
* No signs of systemic illness or underlying foreign body in the ear canal at this time.
Treatment:
* Cleaned left ear canal with a gentle otic cleanser.
* Administered antibiotic and antifungal ear drops into the left ear.
* Provided anti-inflammatory injection (given in consult).
Plan:
* Prescribed topical ear medication for twice daily application for 10 days.
* Recommend recheck in 10-14 days to assess response to treatment and repeat ear cytology.
* Discussed potential underlying causes of recurrent otitis and recommended considering allergy work-up if condition recurs.
* Advised owner to monitor for any changes in appetite, activity, or worsening of ear symptoms.
History:
[document the patient's history including presenting complaints, duration, and any relevant background information] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a bullet point list, grouping similar symptoms or information together in one bullet point.)
[List of current medications] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank. Write as a bullet point list.)
[List of current flea, tick, worming, heartworm medication and frequency of administration] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank. Write as a bullet point list.)
Examination:
Body condition = [document body condition] (Only include if explicitly mentioned in transcript, context or clinical note. Write on the same line.)
Weight = [record patient body weight in kg] (Only include if explicitly mentioned in transcript, context or clinical note. Write on the same line.)
Dental exam = [record the dental examination findings] (Only include if explicitly mentioned in transcript, context or clinical note, else print “not recorded”. Write on the same line.)
Demeanour = [describe the patient's demeanour] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on the same line.)
Oral mms-[Findings from oral examination] (Only include if explicitly mentioned in transcript, context or clinical note, otherwise include the section header but leave the placeholder blank.)
Chest auscultation- [Findings from chest auscultation, including heart rate and if heart murmur detected](Only include if explicitly mentioned in transcript, context or clinical note, otherwise include the section header but leave the placeholder blank.)
Respiration-[Findings from observation of respiration](Only include if explicitly mentioned in transcript, context or clinical note, otherwise include the section header but leave the placeholder blank.)
Abdominal palpation-[Findings from abdominal palpation](Only include if explicitly mentioned in transcript, context or clinical note, otherwise include the section header but leave the placeholder blank.)
Lymph nodes-[Findings from lymph node examination] (Only include if explicitly mentioned in transcript, context or clinical note, otherwise include the section header but leave the placeholder blank.)
Mentation- [mentation findings](Only include if explicitly mentioned in transcript, context or clinical note, otherwise include the section header but leave the placeholder blank.)
Skin/coat- [Findings from skin and coat examination](Only include if explicitly mentioned in transcript, context or clinical note, otherwise include the section header but leave the placeholder blank.)
Eyes- [Findings from eye examination](Only include if explicitly mentioned in transcript, context or clinical note, otherwise include the section header but leave the placeholder blank.)
Ears-[Findings from ear examination](Only include if explicitly mentioned in transcript, context or clinical note, otherwise include the section header but leave the placeholder blank.)
[Temperature] (Only include if explicitly mentioned in transcript, context or clinical note, otherwise include the section header but leave the placeholder blank.)
Rectal examination- [Findings from rectal examination or anal gland expression] (Only include if explicitly mentioned in transcript, context or clinical note, otherwise print "Not performed"
[other physical examination findings not mentioned above] (Only include if explicitly mentioned in transcript, context or clinical note, otherwise omit section entirely.)
Laboratory: [findings from cytology performed during consult] (Only include if skin or ear cytology is explicitly mentioned in transcript, context or clinical note, else omit section entirely)
Assessment:
[provide an assessment based on the history and examination findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bullet point list of full sentences.)
Treatment:
[document treatment including if a vaccinations, injection or tablet has been given or a procedure performed in consult such as nail trims.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bullet point list of full sentences. Do not include medications here.)
Plan:
[outline the plan for treatment, further investigations, and follow-up] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list. Don't include vaccinations or treatments given in consult in this section.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output. Do not apply a brand name to any treatments I administer in the consult such as ear treatments, antibiotics, vaccination or injections.)