C09971561 / invoice 10000

02/03/2026 NURSE: EC

REASON: Ear & Skin RV

HISTORY:
- Previous ear infection, now improved.
- Not scratching ears or shaking head anymore.
- Still scratching belly.
- Malaseb washes going well.
- Improvement noticed within 3/7 of starting treatment.

APPETITE: Eating and drinking well.

ACTIVITY: Good.

DIET: Royal Canin, plain chicken, occasional steak.

CURRENT MEDICATIONS: Pred - 2 tablets left. Malaseb washes. Ear ointment.

CLINICIAL EXAM:
- Mentation: BAR
- MM: Pink and moist
- CRT: <1s
- Oral and Dental Score: 0/4
- Eyes: Bright and clear
- Ears: Canals externally clean. Ear canals inflamed, waxy debris next to ear drums. Able to see TM bilaterally. Cytology: 10 yeast HPF bilaterally.
- BCS: 3/5
- Abdominal: Not assessed
- Lymph nodes: Not assessed
- HR: Not assessed
- RR: Not assessed
- Temp: Not assessed
- Urogenital: Not assessed
- MSK: Not assessed
- Skin: Inflamed/erythematous skin inguinal region.

ASSESSMENT:
- Ongoing skin inflammation inguinal region.
- Yeast otitis bilaterally.

DISCUSSION:
- Discussed limited anti-itch options for dogs <1 year old.
- Cytopoint injection discussed as alternative anti-itch option - may or may not be suitable depending on inflammation levels.
- If Cytopoint effective, can repeat q4-6/52 until 12/12 of age, then can transition to oral medication.
- Discussed ear cleaner use - can use 30 mins before evening ointment or every second day to avoid head shyness.

TREATMENT:
- Cytopoint 10mg/ml administered.
- Ear cleaner nightly.
- Continue Pred every second day.
- Continue Malaseb washes for another two weeks.

PLAN:
- RV in two weeks post treatment.
- Monitor for return of itch - if slowly returning, can repeat Cytopoint until 12/12 of age.